Deck 4: Patient Assessment

Question 1

While you are taking the medical history of a new patient,the patient mentions having occasional headaches that are quite painful.What is the best way for you to proceed with the interview?

A) Express concern and note this information in writing.
B) Ask the patient a direct question about the pain.
C) Reassure the patient that it is probably nothing serious.
D) Ask the patient open-ended questions about the headaches.

Answer 1

Ask the patient open-ended questions about the headaches.

Question 2

Information that you gather from a patient interview is considered

A) subjective.
B) objective.
C) assessment.
D) evaluation.

Answer 2

subjective.

Question 3

Which statement best describes what it means to have good rapport with patients?

A) You use language they understand.
B) They respect you as a professional.
C) You have smooth,pleasant relationships with them.
D) You are polite and punctual.

Answer 3

You have smooth,pleasant relationships with them.

Question 4

Which medical record system has a standard format that makes it easy to read and audit?

A) Chronologic
B) Problem oriented
C) Progress note
D) Source oriented

Question 5

Objective data include which of the following?

A) Complaints of pain
B) Social history
C) Blood pressure recordings
D) Past medical history

Question 6

Which of the following involves asking a question or summarizing a patient's thoughts?

A) Restatement
B) Clarification
C) Reflection

Question 7

Which of the following includes demographic information?

A) Family history
B) Past history
C) Social history
D) Database
E) ROS

Question 8

Which of the following factors is likely to have the most influence on the accuracy and completeness of the information obtained from the patient during the medical history?

A) The comfort of the chairs in the meeting area
B) The medical assistant's ability to take complete and detailed notes
C) The privacy of the area in which the interview takes place
D) The efficiency of the medical assistant in conducting the interview

Question 9

Which of the following involves stating an observation or recognition of a patient's feeling?

A) Restatement
B) Clarification
C) Reflection

Question 10

Which of the following is a closed question or statement?

A) "Tell me about your headaches."
B) "Does your head hurt?"
C) "How are you feeling?"

Question 11

What is the best way to obtain specific information about a patient when taking the medical history?

A) Summarize the facts revealed by the patient when answering questions.
B) Ask direct questions that can be answered briefly.
C) Restate what the patient has said to check the accuracy of what was heard.
D) Encourage the patient to explain the answers fully.

Question 12

What does it mean when medical assistants display empathy when dealing with patients?

A) They feel sorry for patients who have serious health problems.
B) They are able to hear what patients say without judging the content.
C) They can detach themselves emotionally from the problems of their patients.
D) They truly like and care about each of their patients.

Question 13

Which of the following includes the patient's dietary habits,smoking history,and alcohol consumption?

A) Family history
B) Past history
C) Social history
D) Database
E) ROS

Question 14

Which of the following includes insurance information?

A) Family history
B) Past history
C) Social history
D) Database
E) ROS

Question 15

Which of the following sections of the medical record includes the physical examination findings?

A) Family history
B) Past history
C) Social history
D) Database
E) ROS

Question 16

Which of the following involves repeating or paraphrasing the patient's comments?

A) Restatement
B) Clarification
C) Reflection

Question 17

Which of the following includes childhood diseases?

A) Family history
B) Past history
C) Social history
D) Database
E) ROS

Question 18

The section of the medical history that helps uncover existing or potential health problems is called the

A) database.
B) past history.
C) social history.
D) systems review.

Question 19

Which of the following is an open-ended question or statement?

A) "How old are you?"
B) "Do you smoke?"
C) "What brings you to the office today?"

Question 20

During the physical examination,the patient reports a continual ache in the right elbow.This information is called a(n)

A) functional problem.
B) objective finding.
C) sign.
D) symptom.

Question 21

A medical assistant who is a good listener consistently

A) provides repeated assurances.
B) provides feedback to clarify the patient's message.
C) interrupts the patient to gather more details.
D) limits the amount of time spent on each interview.

Question 22

Which of the following processes involved in active listening seeks to summarize or simplify the sender's thoughts and feelings or to resolve any confusion in the message?

A) Restatement
B) Reflection
C) Clarification
D) Feedback

Question 23

When writing in a paper record and an error is made,which of the following document guidelines is acceptable?

A) Scribble out error.
B) Use whiteout to cover up the error.
C) Erase the error.
D) Draw a line through the error.

Question 24

Which of the following components of the medical history provide a guide to the patient's general health?

A) Chief complaint
B) Family history
C) Social history
D) Systems review

Question 25

Which of the following are learned behaviors that are greatly influenced by our family and cultural backgrounds?

A) Active listening
B) Nonverbal communication
C) Verbal messages
D) None of the above

Question 26

Which of the following is most important when conducting a patient interview?

A) Calling the patient by his or her first name
B) Sharing stories about the neighborhood
C) Providing uninterrupted privacy
D) Documenting every word the patient uses to describe the health problem

Question 27

Which of the following questions or statements would encourage the patient to continue to communicate?

A) "Does your arm hurt?"
B) "Did you hurt yourself?"
C) "Tell me about how your arm feels right now."
D) "Do you have a family history of arthritis?"

Question 28

During patient assessment,which of the following is an example of a subjective finding?

A) Difficulty breathing
B) Temperature
C) Blood pressure and pulse
D) Palpable mass

Question 29

Abnormalities in the cardiovascular system that are discovered during an ROS include

A) deformity of the chest.
B) hypertension and leg cramps.
C) deviated septum.
D) jaundice.

Question 30

Which of the following explains a sign of disease?

A) Patient c/o pain
B) Reports of dizziness for 3 days
C) Abdominal cramping for 2 weeks
D) Elevated blood pressure

Question 31

Lois Anderson was recently diagnosed with a functional disorder of the colon.Which of the following is true about her condition?

A) Her laboratory results are negative.
B) A colonoscopy reveals abnormal tissue.
C) Clinical signs indicate disease.
D) None of the above is true.

Question 32

Which of the following is a good example of an open-ended question?

A) What brings you to the doctor today?
B) Do you have a headache?
C) What is your date of birth?
D) Have you ever broken a bone?

Question 33

Helen Conrad,age 54,was recently diagnosed with epilepsy.She is very upset about the news.A therapeutic interaction might be

A) "Look on the bright side;things could be worse."
B) "The doctor will prescribe medication,which will probably prevent most seizures."
C) Distract the patient by discussing the weather.
D) Offer the patient advice on how to drive safely.
E) Listen attentively while the patient talks about her fears.

Question 34

The medical assistant is responsible for documenting all of the following information except the

A) review of systems.
B) family history.
C) social history.
D) allergies.

Question 35

During a physical examination the patient reports problems with speech and balance.These signs indicate a problem with which system?

A) Respiratory
B) Neurologic
C) Cardiovascular
D) Lymph

Question 36

Sam Hernandez,a 17-year-old patient with burning upon urination,has just been told he has an STD.He had suspected that he had gonorrhea,but he states,"The test must be wrong.I just have a bladder infection." He is displaying which defense mechanism?

A) Suppression
B) Denial
C) Regression
D) Sublimation

Question 37

Therapeutic interactions with children include all of the following except

A) allowing the child to decide whether a breathing treatment is needed.
B) permitting the child to play with your stethoscope.
C) praising the child for cooperative behavior.
D) playing a game to distract the child.

Question 38

Sally Tipoke,age 17,is scheduled for her first Pap test today.She appears anxious and scared.Choose the medical assistant's most appropriate statement.

A) "There's no need to worry about the test.Dr.Smith never hurts anyone."
B) "You look worried about the exam.Can I answer any questions?"
C) "If you just think about something positive,it will be over before you know it."
D) "Dr.Smith expects you to stay still during the exam."

Question 39

Mrs.Elizabeth Stewart was recently diagnosed with diabetes mellitus type 2.She refuses to meet with a dietician because,she states,"The tests must be wrong.No one in my family has diabetes." Which defense mechanism is she displaying?

A) Sublimation
B) Denial
C) Repression
D) Suppression

Question 40

Which of the following is not true of holistic patient care?

A) The focus of care is the patient's disease process.
B) The physician considers the patient's ability to pay for treatment.
C) The patient's emotional state is investigated.
D) The medical assistant investigates lifestyle factors that may contribute to disease.

Question 41

The grandmother of a young patient reports that the child has had a temperature of 101.6 $\degree$ for 2 days.This information would be documented in the __________ part of a SOAPE chart note.

Question 42

Which type of data collection is NOT associated with holistic care?

A) Physical
B) Cognitive
C) Social
D) Behavioral

Question 43

The __________ component of the medical history contains details about the patient's insurance,address,and date of birth.

Question 44

__________ data include the patient's blood pressure,TPR,and weight.

Question 45

The physician's initial impression of what is wrong with the patient is called the __________ diagnosis.

Question 46

When a verbal message matches the sender's nonverbal body language,the message is considered __________.

Question 47

The __________ of the interview should summarize the information the medical assistant learned while communicating with the patient and should outline patient expectations of care.

Question 48

The medical assistant must consistently request __________ from the patient to determine the patient's understanding of the message.

Question 49

A detailed description of the anatomic location of a wound would be documented in the __________ area of a SOAPE format.

Question 50

Which of the following is considered a safeguard mandated by HIPAA?

A) Passwords access to all electronic health records
B) Computer monitor shields
C) Turning monitors away from patient traffic areas
D) All of the above

Question 51

The physician's initial impression of the patient's presenting problem is called the __________.

Question 52

__________ care considers the patient as a whole including the physical,emotional,social,economic,and spiritual needs of the person.

Question 53

When writing progress (SOAP)notes,in which section would the provider's preliminary diagnosis of the cause of the patient's chief complaint be placed?

A) S
B) O
C) A
D) P

Question 54

The __________ is the physician's approach to managing the patient's health problem.

Question 55

During the __________ phase of the interview,medical assistants should introduce themselves and state the purpose of the interview.

Question 56

The __________ in POMR charts lists the patient's diagnoses in chronologic order.

Question 57

Developing patient __________ means the medical assistant has developed a positive relationship with the patient.

Question 58

Which of the following is a stage 3 requirement for Medicare and Medicaid EHR Incentive Program?

A) Providers are expected to show improved patient outcomes.
B) Maintain current patient medication list.
C) Include lab test results in patient's EHR.
D) Provide summary of care for patients transferring to another provider.

Question 59

__________ are subjective reports given by patients about how they feel with a particular health problem.

Question 60

When SOAPE documentation is used,the __________ documentation provides feedback on the results of treatment.

Question 61

Providing patients with automatic reassurance when they express a concern is part of a therapeutic relationship.

Question 62

Describe the four sections of the POMR.

Question 63

When conducting a patient interview,the medical assistant should sit behind a desk with arms crossed and wait for the patient to establish eye contact.

Question 64

The most effective distance between a patient and the medical assistant conducting an interview is approximately 2 to 3 feet.

Question 65

A patient interview may be conducted in a quiet corner of the waiting room.

Question 66

When you begin working in the healthcare environment,it will be important that you follow HIPAA regulations about patient confidentiality.Summarize four important factors to consider when complying with HIPAA.

Question 67

Describe the organization of SOAPE notes.

Question 68

Children should always be given a choice whether to take their medication.

Question 69

Define open-ended and closed questions and statements and provide an example of each.

Question 70

An example of an objective sign of disease is the patient's reported level of pain.

Question 71

You are conducting an interview with a new patient who appears very anxious.Summarize four ways of using therapeutic nonverbal language to enhance the quality of the patient interaction.

Question 72

Gathering details about a patient's use of over-the-counter medications is very important during a patient interview.

Question 73

Give a minimum of four rules that must be followed when documenting in a patient's paper record.

Question 74

Value systems are learned beliefs and behaviors that can affect therapeutic relationships.

Question 75

Detail how to make a correction in a patient's paper record.

Question 76

Identify the legal and ethical issues associated with the medical record.

Question 77

Issues of privacy are important to adolescent patients.

Question 78

Research on the significance of body language indicates that 50% of the message received by patients is interpreted from the caregiver's nonverbal language.

Question 79

__________ is an attempt by the patient to hide a negative feeling he or she believes is unacceptable by doing the exact opposite.

Question 80

The best method of ensuring that the patient understands a patient education intervention is to have the patient repeat back the details learned.