Question 1

Which of the following health care notes is NOT usually authored in a hospital?

Accepted Answer

A)  Admission summary 
B)  Clinic note 
C)  Daily hospital/progress note 
D)  Discharge summary 
E)  Emergency department note 
A)  Admission summary 
B)  Clinic note 
C)  Daily hospital/progress note 
D)  Discharge summary 
E)  Emergency department note

Question 2

According to the following discharge summary, which of the following is NOT true about this patient? Discharge Physical Examination
Temp: 98.6; RR: 24; HR: 86; BP: 100/64.
Gen: WDWN. Alert.
CV: RRR.
Resp: CTA.
GI: Abdomen soft, nondistended, mild tenderness to palpation over the surgical incisions. Three small horizontal surgical wounds in her abdomen. Wounds clean, dry, and intact.
Activity
No restrictions.

Accepted Answer

A)  The patient does not have a fever. 
B)  The patient experiences mild tenderness when her surgical incisions are touched. 
C)  The patient's heart is beating rapidly. 
D)  The patient looks well-developed and well-nourished. 
E)  The patient's lungs sound clear. 
A)  The patient does not have a fever. 
B)  The patient experiences mild tenderness when her surgical incisions are touched. 
C)  The patient's heart is beating rapidly. 
D)  The patient looks well-developed and well-nourished. 
E)  The patient's lungs sound clear.

Question 3

Which of the following would NOT describe a patient with a normal physical exam?

Accepted Answer

A)  CTA, RRR 
B)  CTA, SOB 
C)  NAD, WDWN 
D)  PERRLA, A&O 
E)  WNL 
A)  CTA, RRR 
B)  CTA, SOB 
C)  NAD, WDWN 
D)  PERRLA, A&O 
E)  WNL

Question 4

Which of the following is not part of the health record?

Accepted Answer

A)  Family history 
B)  Past employment history 
C)  Past surgical history 
D)  Chief complaint 
E)  History of present illness 
A)  Family history 
B)  Past employment history 
C)  Past surgical history 
D)  Chief complaint 
E)  History of present illness

Question 5

Interpret the following abbreviations: "The Pt is 5y/o."

Accepted Answer

A)  The patient is 5 years old. 
B)  The patient is 5 years under observation. 
C)  The prescription is 5 years old. 
D)  The prescription is 5 years under observation. 
E)  None of these. 
A)  The patient is 5 years old. 
B)  The patient is 5 years under observation. 
C)  The prescription is 5 years old. 
D)  The prescription is 5 years under observation. 
E)  None of these.

Question 6

Which of the following is an accurate breakdown of the abbreviation SC?

Accepted Answer

A)  signa care = signa (label) + care = carefully labeled 
B)  subcutaneous = sub (above) + cutane/o (skin) = above the skin 
C)  subcutaneous = sub (beneath) + cutane/o (skin) = beneath the skin 
D)  subcutaneous = sub (through) + cutane/o (muscle) = through the muscle 
E)  supportive care (abbreviation comes from regularly used English words) 
A)  signa care = signa (label) + care = carefully labeled 
B)  subcutaneous = sub (above) + cutane/o (skin) = above the skin 
C)  subcutaneous = sub (beneath) + cutane/o (skin) = beneath the skin 
D)  subcutaneous = sub (through) + cutane/o (muscle) = through the muscle 
E)  supportive care (abbreviation comes from regularly used English words)

Question 7

Your belly button is located on the ________ part of your body.

Accepted Answer

A)  anterior, lateral 
B)  anterior, medial 
C)  dorsal, lateral 
D)  dorsal, medial 
E)  lateral, medial 
A)  anterior, lateral 
B)  anterior, medial 
C)  dorsal, lateral 
D)  dorsal, medial 
E)  lateral, medial

Question 8

After a car accident, the medical professional asks the patient questions about her name, location, and the date. The patient is able to accurately answer all of the questions. The patient can be classified as:

Accepted Answer

A)  A&O. 
B)  PERRLA. 
C)  NAD. 
D)  ROS. 
E)  WDWN. 
A)  A&O. 
B)  PERRLA. 
C)  NAD. 
D)  ROS. 
E)  WDWN.

Question 9

The first part of most medical notes that includes such information as medical history, duration and quality of the problem, and any exacerbating or relieving factors for that problem is known as the ________ part.

Accepted Answer

A)  subjective. 
B)  objective. 
C)  assessment. 
D)  plan. 
E)  none of these. 
A)  subjective. 
B)  objective. 
C)  assessment. 
D)  plan. 
E)  none of these.

Question 10

Read the following discharge summary: Hospital Course
Mrs) Collach was admitted to the medical service. She was placed on NPO status and given IVF and analgesics. An ultrasound revealed gallstones in the common bile duct as the etiology for Mrs. Collach's pancreatitis. Surgery was consulted. On hospital day 2, Mrs. Collach was taken to the OR for laparoscopic choledocholithectomy and cholecystectomy. She tolerated the procedure well. She began a postoperative refeeding plan with a low-protein, low-fat diet. She tolerated advancing the diet, and 2 days after her surgery, her pain had improved enough that she was discharged home.
According to this summary, which of the following is true?

Accepted Answer

A)  Mrs. Collach could eat a low-protein, low-fat diet when she was first admitted to the hospital. 
B)  Mrs. Collach spent some time in the intensive care unit. 
C)  Mrs. Collach was given palliative care throughout her hospital stay. 
D)  Mrs. Collach was given a low-protein, low-fat diet before her operation. 
E)  Mrs. Collach was not allowed to have anything by mouth and was given intravenous fluids when she was first admitted to the hospital. 
A)  Mrs. Collach could eat a low-protein, low-fat diet when she was first admitted to the hospital. 
B)  Mrs. Collach spent some time in the intensive care unit. 
C)  Mrs. Collach was given palliative care throughout her hospital stay. 
D)  Mrs. Collach was given a low-protein, low-fat diet before her operation. 
E)  Mrs. Collach was not allowed to have anything by mouth and was given intravenous fluids when she was first admitted to the hospital.

Question 11

A PACU is a(n):

Accepted Answer

A)  care unit for cardiac patients. 
B)  intensive care unit for children. 
C)  intensive care unit for patients. 
D)  postanesthesia care unit. 
E)  recovery room following an operation. 
A)  care unit for cardiac patients. 
B)  intensive care unit for children. 
C)  intensive care unit for patients. 
D)  postanesthesia care unit. 
E)  recovery room following an operation.

Question 12

A patient was given a prescription with the following information: "Sig. 5 mL PO BID x 10 days." Which is the most accurate description of the patient prescription?

Accepted Answer

A)  The medication will be taken as needed for ten days. 
B)  The medication will be taken by mouth once a day for ten days. 
C)  The medication will be taken by mouth twice a day for ten days. 
D)  The medication will be taken intravenously for ten days. 
E)  The medication will be taken subcutaneously for ten days. 
A)  The medication will be taken as needed for ten days. 
B)  The medication will be taken by mouth once a day for ten days. 
C)  The medication will be taken by mouth twice a day for ten days. 
D)  The medication will be taken intravenously for ten days. 
E)  The medication will be taken subcutaneously for ten days.

Question 13

Which of the following is NOT an abbreviation that refers to a health care facility or department?

Accepted Answer

A)  CTA 
B)  ECU 
C)  ER 
D)  OR 
E)  PACU 
A)  CTA 
B)  ECU 
C)  ER 
D)  OR 
E)  PACU

Question 14

The following is an excerpt from a patient's medical record. T: 98.5; HR: 60; RR: 20; BP: 112/70.
General: Pleasant, responsive. No acute distress.
HEENT: PERRLA. Mucous membranes moist and pink.
Resp: CTA. No wheezes, rales, rhonchi, or crackles. Good air exchange. No increased work of breathing.
According to this information, which is NOT true about the patient?

Accepted Answer

A)  The patient is afebrile. 
B)  The patient is alert. 
C)  The patient's eyes are not reacting to light. 
D)  The patient's heart rate is 60. 
E)  The patient's respiratory rate is 20. 
A)  The patient is afebrile. 
B)  The patient is alert. 
C)  The patient's eyes are not reacting to light. 
D)  The patient's heart rate is 60. 
E)  The patient's respiratory rate is 20.

Question 15

Read the following health record excerpt: Emergency Department Course:
Elizabeth arrived in the ED lethargic, but responsive. Given her history and vomiting, we were concerned about diabetic ketoacidosis. The patient's finger stick blood sugar test result of 320 confirmed hyperglycemia, and a urinalysis revealed both glucosuria and ketonuria. An IV was started and labs were sent for review. Chemistry profile showed hypernatremia, hypokalemia, and acidemia. The pediatric intensive care team was contacted for patient transfer to the PICU.
Disposition: Transfer to PICU.
According to this excerpt, Elizabeth was transferred to the:

Accepted Answer

A)  emergency department. 
B)  laboratory. 
C)  pathology. 
D)  pediatric intensive care unit. 
E)  postanesthesia care unit. 
A)  emergency department. 
B)  laboratory. 
C)  pathology. 
D)  pediatric intensive care unit. 
E)  postanesthesia care unit.

Question 16

A patient has a rash on the top of both of his hands. Which is the correct medical term for the rash's location?

Accepted Answer

A)  Bilateral, dorsum 
B)  Bilateral, palmar 
C)  Bilateral, plantar 
D)  Unilateral, dorsum 
E)  Unilateral, palmar 
A)  Bilateral, dorsum 
B)  Bilateral, palmar 
C)  Bilateral, plantar 
D)  Unilateral, dorsum 
E)  Unilateral, palmar

Question 17

The course of action consistent with a health care provider's assessment is known as a(n):

Accepted Answer

A)  subjective. 
B)  objective. 
C)  assessment. 
D)  plan. 
E)  none of these. 
A)  subjective. 
B)  objective. 
C)  assessment. 
D)  plan. 
E)  none of these.

Question 18

If an infection stays in a certain part of the body, it is:

Accepted Answer

A)  degenerate. 
B)  localized. 
C)  malignant. 
D)  recurrent. 
E)  systemic. 
A)  degenerate. 
B)  localized. 
C)  malignant. 
D)  recurrent. 
E)  systemic.

Question 19

PERRLA means :

Accepted Answer

A)  pathogen is emerging, responsive, and responsive to adversity. 
B)  patient is equalized, recovering, responsive, and adjusting. 
C)  physical exam has been reported, responded to, and accepted by insurance. 
D)  pupils are equal, round, and reactive to light and accommodation. 
A)  pathogen is emerging, responsive, and responsive to adversity. 
B)  patient is equalized, recovering, responsive, and adjusting. 
C)  physical exam has been reported, responded to, and accepted by insurance. 
D)  pupils are equal, round, and reactive to light and accommodation.

Question 20

Which of the following pairs of abbreviations are opposites?

Accepted Answer

A)  IM, IV 
B)  IV, CVL 
C)  NPO, PR 
D)  PO, NPO 
E)  SC, IM 
A)  IM, IV 
B)  IV, CVL 
C)  NPO, PR 
D)  PO, NPO 
E)  SC, IM

Which of the following health care notes is NOT usually authored in a hospital?

Which of the following would NOT describe a patient with a normal physical exam?

Which of the following is not part of the health record?

Interpret the following abbreviations: "The Pt is 5y/o."

Which of the following is an accurate breakdown of the abbreviation SC?

Your belly button is located on the ________ part of your body.

After a car accident, the medical professional asks the patient questions about her name, location, and the date. The patient is able to accurately answer all of the questions. The patient can be classified as:

The first part of most medical notes that includes such information as medical history, duration and quality of the problem, and any exacerbating or relieving factors for that problem is known as the ________ part.

A PACU is a(n):

A patient was given a prescription with the following information: "Sig. 5 mL PO BID x 10 days." Which is the most accurate description of the patient prescription?

Which of the following is NOT an abbreviation that refers to a health care facility or department?

A patient has a rash on the top of both of his hands. Which is the correct medical term for the rash's location?

The course of action consistent with a health care provider's assessment is known as a(n):

If an infection stays in a certain part of the body, it is:

PERRLA means :

Which of the following pairs of abbreviations are opposites?

Introduction to Medical Language

The Integumentary System Dermatology

The Musculoskeletal System Orthopedics

The Nervous System Neurology and Psychiatry

The Sensory System Ophthalmology and Otolaryngology

The Endocrine System Endocrinology

The Blood and Lymphatic Systems Hematology and Immunology

The Cardiovascular System Cardiology

The Respiratory System Pulmonology

The Gastrointestinal System Gastroenterology

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The Female Reproductive System Gynecology, Obstetrics, and Neonatology

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Exam 2: Introduction to Health Records

Which of the following health care notes is NOT usually authored in a hospital?

Which of the following would NOT describe a patient with a normal physical exam?

Which of the following is not part of the health record?

Interpret the following abbreviations: "The Pt is 5y/o."

Which of the following is an accurate breakdown of the abbreviation SC?

Your belly button is located on the ________ part of your body.

After a car accident, the medical professional asks the patient questions about her name, location, and the date. The patient is able to accurately answer all of the questions. The patient can be classified as:

The first part of most medical notes that includes such information as medical history, duration and quality of the problem, and any exacerbating or relieving factors for that problem is known as the ________ part.

A PACU is a(n):

A patient was given a prescription with the following information: "Sig. 5 mL PO BID x 10 days." Which is the most accurate description of the patient prescription?

Which of the following is NOT an abbreviation that refers to a health care facility or department?

A patient has a rash on the top of both of his hands. Which is the correct medical term for the rash's location?

The course of action consistent with a health care provider's assessment is known as a(n):

If an infection stays in a certain part of the body, it is:

PERRLA means :

Which of the following pairs of abbreviations are opposites?

Introduction to Medical Language

The Integumentary System Dermatology

The Musculoskeletal System Orthopedics

The Nervous System Neurology and Psychiatry

The Sensory System Ophthalmology and Otolaryngology

The Endocrine System Endocrinology

The Blood and Lymphatic Systems Hematology and Immunology

The Cardiovascular System Cardiology

The Respiratory System Pulmonology

The Gastrointestinal System Gastroenterology

The Urinary and Male Reproductive Systems Urology

The Female Reproductive System Gynecology, Obstetrics, and Neonatology

Filters