Deck 36: Patient Interview and History

Question 1

Which of the following are other names for cocaine?

A) Snow, crack
B) Acid, microdot
C) Pot, grass, reefer
D) Angel dust, rocket fuel
E) Monkey, white stuff

Answer 1

Snow, crack

Question 2

Which of the following commonly abused drugs are amphetamines/stimulants?

A) Phenobarbital and amobarbital
B) Valium, Ativan, and Librium
C) Dexedrine, Benzedrine, and methamphetamine
D) Butisol and secobarbital
E) Anadrol and Depo-testosterone

Answer 2

Dexedrine, Benzedrine, and methamphetamine

Question 3

Angel dust is also known as ____.

A) LSD
B) cocaine
C) PCP
D) opium
E) heroin

Answer 3

PCP

Question 4

"You seem to be making progress, don't you agree?" is an example of which method of collecting patient data?

A) Asking leading questions
B) Probing
C) Challenging the patient
D) Asking open-ended questions
E) Encouraging the patient to take the lead

Question 5

Which of the following statements applies to HIPAA requirements?

A) Long-term costs of treatment choices must be explained to patients.
B) A privacy notice must be prominently posted within the hospital.
C) Patients should know the identity of people involved in care.
D) Patients should be informed of available resources for resolving disputes.
E) Reasonable continuity of care should be provided to patients.

Question 6

Which of the following statements does not apply to the Patient's Bill of Rights (Patient Care Partnership)?

A) Patients should know the long-term costs of treatment choices.
B) A privacy notice must be prominently posted within the hospital.
C) The identity of people involved in care should be known to patients.
D) Patients should be informed of available resources for resolving disputes.
E) Patients can choose a representative to make healthcare decisions.

Question 7

Which of the following are common effects of LSD?

A) Slowed thinking, slowed reflexes, slowed respiration, loss of anxiety
B) Grandiose feelings, hallucinations, mystical experiences, flashbacks
C) Decreased level of consciousness, detachment, drowsiness, impaired judgment
D) Altered mental status, confusion, paranoia,
E) Hyperactivity followed by exhaustion, insomnia, loss of appetite

Question 8

The practitioner's diagnosis or impression of the patient's condition is the ____.

A) subjective data
B) assessment
C) objective data
D) plan of action
E) problem list

Question 9

Which of the following information would be documented under the plan of action?

A) Medications prescribed and tests to be done
B) Physician's diagnosis
C) Patient's chief complaint
D) Results of the physician's examination
E) Patient's vital signs

Question 10

During a patient interview, you note signs of anxiety in the patient. You may be able to help the patient by ____.

A) stopping the interview
B) letting him take the lead
C) bringing in the physician
D) telling him to calm down
E) allowing him to describe his feelings

Question 11

The information in the patient's chart is ____.

A) a reminder to the medical assistant of what has occurred in the past
B) primarily for the third-party payer's use
C) a mechanism to provide information to the patient about treatments
D) a legal record of treatment rendered
E) a tool for diagnosing illness

Question 12

Which of the following is characteristic of depression?

A) It occurs most commonly in children.
B) The signs of depression are the same as the signs of substance abuse or addiction.
C) Symptoms include difficulty falling asleep, loss of appetite, and loss of energy.
D) Depression is always easy to diagnose.
E) Depression seems to occur most frequently between ages 20 and 30.

Question 13

Methods of collecting patient data include mirroring, which includes ____.

A) blocking further communication
B) restating what the patient says almost exactly as the patient says it
C) interpreting what you believe the patient is saying
D) motivating the patient to describe the situation in his own way
E) asking closed-ended questions

Question 14

Which of the following is appropriate for conducting a successful interview?

A) Tell the patient that you "need to take a history"
B) Avoid the use of icebreakers
C) Give the patient your opinion about a diagnosis
D) Ask leading questions so the patient knows the right answer
E) Assist the patient to a private room and close the door

Question 15

The need for ____ in the medical record makes it essential that medical terminology and precise descriptions are used when charting.

A) conciseness
B) completeness
C) clarity
D) confidentiality
E) chronological order

Question 16

"Where would you like to begin?" is an example of which method of collecting patient data?

A) Challenging the patient
B) Asking hypothetical questions
C) Encouraging the patient to take the lead
D) Asking open-ended questions
E) Focusing on the patient

Question 17

Which of the following is charted as subjective data?

A) Test results
B) Practitioner's examination
C) Patient's chief complaint
D) Vital signs
E) Plan of action

Question 18

Which of the following offers the patient little freedom to explain his answers and requires only yes-or-no answers?

A) Probing
B) Agreeing or disagreeing with the patient
C) Asking leading questions
D) Asking closed-ended questions
E) Mirroring the patient's responses

Question 19

Which of these patient behaviors is a classic symptom of depression?

A) Profound sadness
B) Rapid speech
C) Obsession with exercising
D) Anxiety about entering the health-care system
E) Sleeping soundly at night

Question 20

Which of the following methods of collecting patient data requires more than a yes-or-no answer and encourages the patient to explain the situation?

A) Asking leading questions
B) Challenging a patient
C) Asking open-ended questions
D) Focusing on the patient
E) Probing

Question 21

Alternating euphoria and apprehension is an effect of ____.

A) depressants
B) anabolic steroids
C) inhalants
D) stimulants
E) cannabinoids

Question 22

An increased heart rate, confusion, anxiety, and paranoia are effects of which of the following drugs?

A) Depressants
B) Ecstasy
C) Anabolic steroids
D) Inhalants
E) Narcotics

Question 23

Maintaining eye contact is a characteristic of which of these methods of data collection?

A) Asking closed-ended questions
B) Verbalizing the implied
C) Asking open-ended questions
D) Focusing on the patient
E) Probing

Question 24

A decreased heart rate and blood pressure, drowsiness, and poor concentration are effects of ____.

A) GHB
B) ecstasy
C) anabolic steroids
D) inhalants
E) amphetamines

Question 25

Which of the following information would you place in the "P" section when using SOAP charting?

A) Physician's examination
B) Physician's diagnosis
C) Patient's chief complaint
D) Test results
E) Patient education

Question 26

Irene is a 26-year-old patient who is in the office for her annual physical examination. While you are interviewing her, she says she is feeling wonderful. She tells you she has been having mystical experiences and seems unusually aware of things around her. Which of the following drugs has she probably taken?

A) GHB
B) LSD
C) Heroin
D) Ativan
E) Benzedrine

Question 27

The question "Are you sure about that? It doesn't make sense to me." represents which method of collecting patient data?

A) Asking closed-ended questions
B) Focusing on the patient
C) Challenging the patient
D) Encouraging the patient to evaluate his situation
E) Probing

Question 28

When you assume an open and relaxed body posture, you are demonstrating which data collection method?

A) Asking open-ended questions
B) Focusing on the patient
C) Asking hypothetical questions
D) Encouraging the patient to evaluate his situation
E) Agreeing with the patient

Question 29

John is a 15-year-old patient who plays on his high school basketball team. He says he is proud to be on the team's "first string." His mother brought him to the office because he is experiencing hearing loss and has frequent spasms in his legs. Which of the following are possible causes of these symptoms?

A) GNB
B) Ecstasy
C) LSD
D) Paint thinner
E) Anadrol

Question 30

In response to your questions about social activities, Venira says she and her boyfriend have been dating for two years now, and they are very happy together. Something about her expression makes you think there might be more to the story, however. After a moment, she adds that her boyfriend, a high school football star, has been getting more and more aggressive and recently hit her during an argument. Which of the following might be the cause of this change in his behavior?

A) Librium
B) Ecstasy
C) Anadrol
D) Marijuana
E) Valium

Question 31

Which of the following does not apply to HIPAA requirements?

A) Patient consent is required to disclose protected information.
B) Health-care facilities must provide patients with a written notice of their privacy practices.
C) The medical assistant should be informed of available resources for resolving disputes.
D) Health-care facilities must inform patients, in writing, about disclosure of identifiable health information.
E) The patient's written authorization is required for disclosures not permitted by a hospital's privacy notice.

Question 32

Which of the following is an ineffective means of collecting data?

A) Asking open-ended questions
B) Probing for more information
C) Asking hypothetical questions
D) Encouraging patient to take the lead
E) Mirroring the patient's responses

Question 33

Which of the following approaches allows you to determine the patient's knowledge of the situation and whether it is accurate?

A) Agreeing with the patient
B) Asking questions that require yes-or-no answers
C) Asking hypothetical questions
D) Probing for more information
E) Challenging the patient

Question 34

Using SOAP charting, where would you document measurable information?

A) Subjective data
B) Objective data
C) Assessment
D) Plan of action
E) Test results

Question 35

Which method of data collection does the question "What do you think is going on with you?" represent?

A) Asking open-ended questions
B) Focusing on the patient
C) Asking hypothetical questions
D) Mirroring the patient's responses
E) Encouraging the patient to evaluate his situation

Question 36

Which of the following applies to HIPAA requirements?

A) Patients should know the long-term costs of treatment choices.
B) Patients should know the identity of people involved in care.
C) Patients should be informed of available resources for resolving disputes.
D) Healthcare facilities must inform patients, in writing, about disclosure of identifiable health information.
E) To the extent permitted by law, patients may refuse treatment.

Question 37

Asking the patient "Can you tell me more about your symptoms?" is which method of collecting patient data?

A) Asking closed-ended questions
B) Asking open-ended questions
C) Asking hypothetical questions
D) Encouraging patient to take the lead
E) Asking leading questions

Question 38

The question "Where would you like to begin?" represents which method of data collection?

A) Asking open-ended questions
B) Asking hypothetical questions
C) Mirroring the patient's responses
D) Encouraging the patient to evaluate his situation
E) Encouraging the patient to take the lead

Question 39

Which method of patient data collection does the statement "So let me see if I understand; The pain only occurs at night." represent?

A) Asking closed-ended questions
B) Verbalizing the implied
C) Asking open-ended questions
D) Focusing on the patient
E) Challenging the patient

Question 40

The question "What would you do if you had chest pain?" represents which of the following methods of patient data collection?

A) Asking closed-ended questions
B) Asking open-ended questions
C) Asking hypothetical questions
D) Challenging the patient
E) Asking leading questions

Question 41

The patient's facial expressions and body language are examples of ________ communication.

Question 42

Which of the following is an ineffective way to make a patient feel at ease and should never be used?

A) Use icebreakers
B) Fail to maintain eye contact
C) Call a patient "honey" or "sweetie"
D) Ensure privacy
E) Appear relaxed

Question 43

Important information about medications (including herbal and OTC) and allergies is found in which section of the health history form?

A) Personal data
B) Chief complaint
C) History of present illness
D) Past medical history
E) Social and occupational history

Question 44

Which of the following would you place in the "A" section when using SOAP charting?

A) Physician's examination
B) Physician's diagnosis
C) Patient's perceptions
D) Test results
E) Patient education

Question 45

Asking the patient "What do you think about this?" allows the patient to evaluate the situation and form an opinion. This is an example of ____.

A) clarification
B) verbalization
C) reflection
D) hypothesizing
E) probing

Question 46

Which of the following information would you place in the "S" section when using SOAP charting?

A) Physician's examination
B) Physician's diagnosis
C) Patient's perceptions
D) Test results
E) Patient education

Question 47

Which method for maintaining notes on a patient chart is arranged according to who provided the information?

A) Conventional (source-oriented medical records)
B) Problem-oriented medical records
C) Computerized medical records
D) SOAP records
E) Patient-oriented medical records

Question 48

Which method for maintaining notes on a patient chart uses a combination of SOMR and POMR?

A) Conventional (source oriented medical records)
B) Problem-oriented medical records
C) Computerized medical records
D) SOAP records
E) Patient-oriented medical records

Question 49

Which section of the health history form includes information about the health of the patient's family?

A) Personal data
B) Past medical history
C) Family history
D) Social and occupational history
E) Review of Systems

Question 50

A subjective statement made by a patient describing the patient's most significant symptoms or signs of illness is the patient's ________.

Question 51

Which section of the health history form includes questions about and examination (by the practitioner) of all body functions?

A) Chief complaint
B) History of present illness
C) Past medical history
D) Review of systems
E) Social and occupational history

Question 52

Where on the health history form do you find the reason the patient came to visit the practitioner?

A) Personal data
B) Chief complaint
C) History of present illness
D) Past medical history
E) Family history

Question 53

Jill Hanson is a 16-year-old patient who has come to the office complaining of lower abdominal pain. As you interview her, you notice that she seems to have difficulty concentrating on the conversation. She constantly looks toward the closed door of the exam room, and she asks you several times whether the doctor is "nice." Which of the following would you suspect as the reason for Jill's behavior?

A) Depression
B) Physical abuse
C) Substance abuse
D) Aggression
E) Anxiety

Question 54

The section of the health history form that contains information about when the problem started and what the patient has done to treat it is the ____.

A) personal data section
B) chief complaint section
C) history of present illness section
D) past medical history section
E) family history section

Question 55

Kenneth Little is complaining of burning when he voids. Because you suspect he has a urinary tract infection, you ask him more questions about the appearance of the urine, how often he has the urge to urinate, if he has any hesitancy, and when the symptoms started. Which interviewing skill does this demonstrate?

A) Effective listening
B) Awareness of nonverbal cues
C) Broad knowledge base
D) Summarizing to form a general picture
E) Making the patient feel at ease

Question 56

Mr. Henderson denies that he is in pain, but you noticed that he grimaces when he stands up and that he moves very slowly and carefully. Which interview skill are you using?

A) Effective listening
B) Awareness of nonverbal cues
C) Broad knowledge base
D) Summarizing to form a general picture
E) Doing research before the interview

Question 57

____ are used extensively by large clinics and practices and includes the database, problem list, treatment plan, and progress notes.

A) Conventional (source-oriented medical records)
B) Problem-oriented medical records
C) Computerized medical records
D) SOAP records
E) Patient-oriented medical records

Question 58

Effective ________ means hearing what the patient says, thinking about it, and responding appropriately.

Question 59

Where on the health history form do you document information taken from the administrative sheet?

A) Personal data
B) Chief complaint
C) History of present illness
D) Social and occupational history
E) Family history

Question 60

The ____ section of the health history form gives the practitioner information about exposure to hazardous substances, sexual practices, and chemical use habits.

A) personal data
B) history of present illness
C) family history
D) past medical history
E) social and occupational history

Question 61

A physical or psychological dependence on a substance is called a(n) ________.

Question 62

If you suspect a patient has been abused, you must report it to your supervisor or the ________.

Question 63

Classic symptoms of ________ are profound sadness and fatigue.

Question 64

The method of collecting patient data that requires more than a yes-or-no answer is asking _________ questions.

Question 65

"White coat syndrome" is a type of _______ related to seeing a medical provider.

Question 66

Only the licensed practitioner can make a(n) ________, based on the patient's symptoms and complaints.

Question 67

An unlikely explanation for an injury may be a sign of ________.

Question 68

Data that is readily apparent and measurable is _______ data.

Question 69

You must have a broad ________ base to be able to ask questions that will elicit the most meaningful information about the patient.

Question 70

Taking larger-than-prescribed doses of a medication is an example of _______.

Question 71

Signs of substance abuse or ________ can be mistaken for depression.

Question 72

Most patient charts are arranged with the entries in reverse _______ order.

Question 73

When the patient shows signs of _______, every effort should be made to help the patient relax and release or reduce these feelings.

Question 74

The method of collecting data that allows you to determine the patient's knowledge of the situation is asking ________ questions.

Question 75

Stating what you believe the patient is suggesting by his response is a technique known as _______.

Question 76

The use of _______ by continuing to ask questions after the patient appears to have finished giving information is an ineffective means of data collection because the patient may feel you are invading her privacy.

Question 77

At the end of an interview, you should ________ the information the patient provided and repeat it back to him for verification.

Question 78

The thoughts, feelings, and perception of a patient are _______ data when you document using the SOAP format.

Question 79

Restating as exactly as possible what the patient said is an example of _______ the patient's responses.

Question 80

Patient interviews should be conducted in ________ and without interruptions.