u u u u u u u u u u u
AcquiringuMedicaluLanguage,u2eu(Jones)uCha
pteru2 IntroductionutouHealthuRecords
1) Whatuisutheuimportanceuofuhealthurecords?
A) Theyucontainuinformationucrucialutoupatientucare.
B) Theyucontainuroadmapsutouaupatient'suhealthuhistory.
C) Theyuprovideuauclearerupictureuofutheubesturouteutoutakeuinufutureutreatmentuofutheupatient.
D) Alluofuthese.
E) Noneuofuthese.
Answer:u u D
Explanation:u Healthurecordsucontainuinformationucrucialutoupatientucare,uareuroadmapsutouaupatien
t'suhealthuhistory,uanduprovideuauclearerupictureuofutheubesturouteutoutakeuinufutureutreatmentuofutheup
atient.
Difficulty:u1uEasy
Topic:u TypesuofuHealthuRecordsuBloo
m's:u Remember
LearninguOutcome:u 02.02uAccessibilit
y:u KeyboarduNavigationuEstuTime:u 0-
1uminute
2) Theufirstupartuofumostumedicalunotesuthatuincludesusuchuinformationuasumedicaluhistory,uduration
uanduqualityuofutheuproblem,uanduanyuexacerbatinguorurelievingufactorsuforuthatuproblemuisuknownuas
utheu part.
A) subjective.
B) objective.
C) assessment.
D) plan.
E) noneuofuthese.
Answer:u u A
Explanation:u Theufirstupartuofumostumedicalunotesuthatuincludesusuchuinformationuasumedicaluhistor
y,udurationuanduqualityuofutheuproblem,uanduanyuexacerbatinguorurelievingufactorsuforuthatuproblemuis
uknownuasutheusubjectiveupartuofutheunote.
Difficulty:u1uEasy
Topic:u TheuSOAPuMethodu
Bloom's:u RememberuLearn
inguOutcome:u 02.01
Accessibility:u KeyboarduNavigationuEs
tuTime:u 0-1uminute
1
Copyrightu2019u©uMcGraw-
HilluEducation.uAllurightsureserved.uNoureproductionuorudistributionuwithoututheuprioruwrittenuconsentuofuMcGraw-
HilluEducation.
mynursytest.store
,DOWNLOAD THE Test Bank for NR Acquiring Medical Language 2nd Edition Jones
u u u u u u u u u u u
3) Informationusuchuasutheupatient'suphysicaluexam,uanyulaboratoryufindings,uanduimagingustudiesu
performeduduringutheuvisituwouldubeucontaineduinuwhichupartuofutheudiagnosticuprocess?
A) Subjective
B) Objective
C) Assessment
D) Plan
E) Noneuofuthese
Answer:u u B
Explanation:u Informationusuchuasutheupatient'suphysicaluexam,uanyulaboratoryufindings,uanduimagin
gustudiesuperformeduduringutheuvisituwouldubeucontaineduinutheuobjectiveupartuofutheudiagnosticuproc
ess.
Difficulty:u1uEasy
Topic:u TheuSOAPuMethodu
Bloom's:u RememberuLearn
inguOutcome:u 02.01
Accessibility:u KeyboarduNavigationuEs
tuTime:u 0-1uminute
4) Afteruauhealthucareuprovideruhasugathereduinformationufromutheupatientuanduperformeduanyuneces
saryuinvestigations,utheuhealthucareuprovideruthenuformulatesua(n)u
,uwhichucouldubeuaudiagnosis,uidentificationuofutheuproblem,uoruaudifferentialudiagnosis.
A) subjective
B) objective
C) assessment
D) plan
E) noneuofuthese
Answer:u u C
Explanation:u Afteruauhealthucareuprovideruhasugathereduinformationufromutheupatientuanduperforme
duanyunecessaryuinvestigationsu(foruexample:uphysicaluexams,ulaboratoryustudies,uoruimagingustudie
s),utheuhealthucareuprovideruthenuformulatesuanuassessment,uwhichucouldubeuaudiagnosis,uidentificati
onuofutheuproblem,uoruaudifferentialudiagnosis.
Difficulty:u1uEasy
Topic:u TheuSOAPuMethodu
Bloom's:u RememberuLearn
inguOutcome:u 02.01
Accessibility:u KeyboarduNavigationuEs
tuTime:u 0-1uminute
2
Copyrightu2019u©uMcGraw-
HilluEducation.uAllurightsureserved.uNoureproductionuorudistributionuwithoututheuprioruwrittenuconsentuofuMcGraw-
HilluEducation.
mynursytest.store
,DOWNLOAD THE Test Bank for NR Acquiring Medical Language 2nd Edition Jones
u u u u u u u u u u u
5) Theucourseuofuactionuconsistentuwithuauhealthucareuprovider'suassessmentuisuknownuasua(n):
A) subjective.
B) objective.
C) assessment.
D) plan.
E) noneuofuthese.
Answer:u u D
Explanation:u Theucourseuofuactionuconsistentuwithuauhealthucareuprovider'suassessmentuisuknownua
suauplan.
Difficulty:u1uEasy
Topic:u TheuSOAPuMethodu
Bloom's:u RememberuLearn
inguOutcome:u 02.01
Accessibility:u KeyboarduNavigationuEs
tuTime:u 0-1uminute
6) WhichuofutheufollowinguisuFALSEuaboututheuSOAPumethod?
A) Diagnosticuworkuinumedicineuisuveryusimilarutoutheuinvestigativeuworkuofuaudetective;uthusutheuS
OAPumethodubeginsuwithuanuanalysisuanduendsuwithucollectingudatautouconfirmutheudiagnosis.
B) MostumedicalunotesushareuauconsistentupatternuinutheiruorganizationuandulayoututhatureflectsutheuS
OAPuthoughtuprocess.
C) SOAPuisuanuacronymuthatustandsuforuSubjective,uObjective,uAssessment,uanduPlan.
D) SOAPureflectsuaugeneraluthoughtuprocessuusedubyumostumedicaluprofessionals.
E) TheuSOAPumethoduisurepeateduinueveryuhealthucareuvisituacrossualludisciplinesuofumedicine.
Answer:u u A
Explanation:u Diagnosticuworkuinumedicineubeginsuwithudataucollectionuanduconcludesuwithuanuanal
ysis.
Difficulty:u1uEasy
Topic:u TheuSOAPuMethodu
Bloom's:u RememberuLearn
inguOutcome:u 02.01
Accessibility:u KeyboarduNavigationuEs
tuTime:u 0-1uminute
3
Copyrightu2019u©uMcGraw-
HilluEducation.uAllurightsureserved.uNoureproductionuorudistributionuwithoututheuprioruwrittenuconsentuofuMcGraw-
HilluEducation.
mynursytest.store
, DOWNLOAD THE Test Bank for NR Acquiring Medical Language 2nd Edition Jones
u u u u u u u u u u u
7) Theustoryuofutheupatient'suproblemuisuknownuas:
A) chiefucomplaint.
B) familyuhistory.
C) historyuofupresentuillness.
D) reviewuofuhistory.
E) socialuhistory.
Answer:u u C
Explanation:u Theustoryuofutheupatient'suproblemuisuknownuasutheuhistoryuofupresentuillness.uDifficult
y:u1uEasy
Topic:u TypesuofuHealthuRecordsuBloo
m's:u Remember
LearninguOutcome:u 02.03uAccessibilit
y:u KeyboarduNavigationuEstuTime:u 0-
1uminute
8) Aureviewuofusystemsuis:
A) audescriptionuofuindividualubodyusystemsuinuorderutoudiscoveruanyusymptomsunotudirectlyur
elatedutoutheumainuproblem.
B) aurecorduofuhabitsulikeusmoking,udrinking,udruguabuse,uandusexualupracticesuthatucanuimpactuh
ealth.
C) anyusignificantuillnessesuthaturunuinutheupatient'sufamily.
D) otherusignificantupastuillnesses,ulikeuhighubloodupressure,uasthma,uorudiabetes.
E) theustoryuofutheupatient'suproblem.
Answer:u u A
Explanation:u Aureviewuofusystemsuisuaudescriptionuofuindividualubodyusystemsuinuorderutoudiscover
uanyusymptomsunotudirectlyurelatedutoutheumainuproblem.
Difficulty:u1uEasy
Topic:u TypesuofuHealthuRecordsuBloo
m's:u Remember
LearninguOutcome:u 02.03uAccessibilit
y:u KeyboarduNavigationuEstuTime:u 0-
1uminute
4
Copyrightu2019u©uMcGraw-
HilluEducation.uAllurightsureserved.uNoureproductionuorudistributionuwithoututheuprioruwrittenuconsentuofuMcGraw-
HilluEducation.
mynursytest.store