Question 1

Data relevant to the social history of older adults includes information on:
A) family support systems.
B) previous health care visits.
C) over the counter medication intake.
D) date of last cancer screening.

Accepted Answer

The social history of older adults includes community and family support systems.

Question 2

George Michaels, a 22-year-old patient, tells the nurse that he is here today to "check his allergies." He has been having "green nasal discharge" for the last 72 hours. How would the nurse document his reason for seeking care?
A) GM is a 22-year-old male here for "allergies."
B) GM came into the clinic complaining of green discharge for the past 72 hours.
C) GM, a 22-year-old male, states that he has allergies and wants them checked.
D) GM is a 22-year-old male here for having "green nasal discharge" for the past 72 hours.

Accepted Answer

Documentation of the chief complaint should always be done by using the patient's own words in quotation marks.

Question 3

Ms. G is being seen for her routine physical examination. She is a college graduate and president of a research firm. Although her exact salary is unknown, she has adequate health insurance. Most of this information is part of Ms. G's _____ history.
A) family
B) past medical
C) personal and social
D) present problem

Accepted Answer

Information such as education and economic condition is part of the personal and social history.

Question 4

Eye examination of the newborn does not routinely include assessment of:
A) the red reflex.
B) the corneal reflex.
C) object tracking.
D) the fundus.

Accepted Answer

The fundus of the eye is not routinely assessed in a newborn.

Question 5

When using the mnemonic OLDCARTS, the A stands for ______________________.

Accepted Answer

The OLDCARTS mnemonic helps make sure that all characteristics of a problem are described in the history of present illness to ensure a comprehensive presentation. The order of recording these characteristics does not need to be consistent.

Question 6

Which of the following formats would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)?
A) Brief SOAP note
B) Comprehensive health history
C) Progress note
D) Referral note

Accepted Answer

Follow-up visits for problems identified in the POMR are recorded in the progress notes. Those visits not identified as problems are recorded using the SOAP format. Careful review of all SOAP notes on a regular basis will detect the emergence of a condition that explains the patient's complaints; at that point, SOAP documentation is stopped.

Question 7

Information recorded about an infant differs from that recorded about an adult, mainly because of the infant's:
A) attention span.
B) developmental status.
C) nutritional differences.
D) source of information.

Accepted Answer

The organizational structure of an infant's record is different because the infant's current and future health are referenced in terms of developmental status.

Question 8

When recording physical findings, which data are recorded first for all systems?
A) Inspection
B) Percussion
C) Palpation
D) Auscultation

Accepted Answer

Physical assessment for all systems begins with inspection.

Question 9

A SOAP note is used in which type of recording system?
A) Preventive care
B) Problemoriented
C) Systems review
D) Traditional treatment

Accepted Answer

A SOAP note-subjective problem data, objective problem data, assessment, and plan- is a type of recording system that has a problem-oriented style.

Question 10

The examiner's evaluation of a patient's mental status belongs in the:
A) history of present illness.
B) review of systems.
C) physical examination.
D) patient education.

Accepted Answer

Mental status assessment, including cognitive and emotional stability and speech and language, is part of the physical examination.

Question 11

Allergies to drugs and foods are generally listed in which section of the medical record?
A) History of present illness
B) Past medical history
C) Social history
D) Problem list

Accepted Answer

The past medical history section contains information such as allergies to drugs and foods and environmental allergies.

Question 12

In which section of the newborn history would you find details of gestational assessment and extrauterine adjustment data?
A) Family
B) Past medical
C) Personal and social
D) Present problem

Accepted Answer

For the newborn, the focus of recorded information is the details of the mother's pregnancy, gestational development, and events occurring since birth. These data are recorded in the present problem section of the history.

Question 13

Which finding is unique to the documentation of a physical examination of an infant?
A) Fontanel size
B) Liver span
C) Prostate size
D) Thyroid position

Accepted Answer

The size and characteristic of the fontanel are unique and important in the assessment of an infant.

Quiz 26: Recording Information

Data relevant to the social history of older adults includes information on:

George Michaels, a 22-year-old patient, tells the nurse that he is here today to "check his allergies." He has been having "green nasal discharge" for the last 72 hours. How would the nurse document his reason for seeking care?

Ms. G is being seen for her routine physical examination. She is a college graduate and president of a research firm. Although her exact salary is unknown, she has adequate health insurance. Most of this information is part of Ms. G's _____ history.

Eye examination of the newborn does not routinely include assessment of:

When using the mnemonic OLDCARTS, the A stands for ______________________.

Which of the following formats would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR) ?

Information recorded about an infant differs from that recorded about an adult, mainly because of the infant's:

When recording physical findings, which data are recorded first for all systems?

A SOAP note is used in which type of recording system?

The examiner's evaluation of a patient's mental status belongs in the:

Allergies to drugs and foods are generally listed in which section of the medical record?

In which section of the newborn history would you find details of gestational assessment and extrauterine adjustment data?

Which finding is unique to the documentation of a physical examination of an infant?