Quiz 21: Patient Assessment

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.

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.

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

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.

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.

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.

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

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.

Which of the following includes insurance information? A) Family history B) Past history C) Social history D) Database E) ROS

Which of the following includes demographic information? A) Family history B) Past history C) Social history D) Database E) ROS

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

Which of the following includes childhood diseases? A) Family history B) Past history C) Social history D) Database E) ROS

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

Which of the following involves repeating or paraphrasing the patient's comments? A) Restatement B) Clarification C) Reflection

Which of the following involves asking a question or summarizing a patient's thoughts? A) Restatement B) Clarification C) Reflection

Which of the following involves stating an observation or recognition of a patient's feeling? A) Restatement B) Clarification C) Reflection

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?"

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?"

Information that you gather from a patient interview is considered A) subjective. B) objective. C) assessment. D) evaluation.

Objective data include which of the following? A) Complaints of pain B) Social history C) Blood pressure recordings D) Past medical history

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.

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.

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?"

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

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

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.

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.

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

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.

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

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."

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.

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.

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

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

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

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

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?

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

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.

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

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.

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

Which type of data collection is NOT associated with holistic care? A) Physical B) Cognitive C) Social D) Behavioral

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

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

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.

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

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

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

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

Issues of privacy are important to adolescent patients.

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

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

It is acceptable to skip lines when documenting to give the physician room to enter a note after the patient has been seen.

Documenting that the patient reports a headache of 3 days' duration is part of the objective data in the POMR record.

A sign is a patient-reported indication of disease.

Congruence is achieved when the communicator's words and body language are delivering the same message.

The initial diagnosis made by the physician after completion of the physical examination is the differential diagnosis.

The chief complaint may also be called the patient's present illness.

A patient's lifestyle factors would be included in the family history section of the medical history.

The medical assistant is responsible for performing the systems review.

Restatement is a valuable active listening technique, because it acknowledges the emotions displayed by the patient during the interview.

Asian patients may have difficulty maintaining eye contact during an interview.

If the medical assistant is caring for an aging patient who has difficulty hearing, he or she should ignore the patient and direct the interaction toward a family member.

When communicating with a sick child, it is important to direct all questions toward the child's parent.

It is important for the medical assistant to keep arms and legs crossed during an interview to communicate authority to the patient.

The easiest way to get specific information from the patient is to use open-ended questions.

Giving advice when it is requested by a patient is an effective way of displaying concern.

A patient who accuses the medical assistant of being short tempered when the patient has just screamed at the medical assistant about a bill is displaying the defense mechanism of projection.

A 6-year-old child who refuses to leave her mother's lap during a physical examination is displaying regression.

When the medical assistant asks the patient about the duration of the symptoms, the question refers to the length of time the patient has had the symptoms.

The SOMR begins with a list of the patient's health problems.

Progress notes in the POMR include the use of SOAPE documentation.

The physician's decision to refer a patient to a dietician is documented under the assessment category of SOAP records.

Subjective data include the patient's report of injuries and resultant pain level.

The size and shape of a wound would be included in the objective area of the progress notes of SOAPE documentation.