Answers | 2026 Updated | 100% Correct - South
University
, Question 1
When recording assessments during the construction of the problem-oriented medical record,
the examiner should:
Answer: Assess each unique problem once a list of problems has been constructed.
Rationale: The problem-oriented medical record (POMR) is organized around a list of patient
problems. After identifying each problem, the examiner develops a focused assessment and plan for that
specific problem. This approach ensures that each active issue receives appropriate evaluation rather
than a generalized assessment that may overlook individual concerns-3-6.
Question 2
What finding is unique to the documentation of a physical examination of an infant?
Answer: The size and characteristics of the fontanel.
Rationale: Fontanels (soft spots) are unique to infants and provide critical information about
hydration status, intracranial pressure, and skeletal development. Findings such as liver span, prostate
size, thyroid position, and visual acuity are relevant to adult assessments but do not apply to infant
examinations. The fontanel assessment is a key component of the infant neurological and developmental
evaluation-3-6.
, Question 3
The quality of a symptom, such as pain, is subjective information that should be:
Answer: Recorded in the history using a 1-to-10 scale.
Rationale: Pain is inherently subjective—only the patient can perceive and rate its severity. Using
a standardized pain scale (0–10) allows for objective tracking of subjective data over time, facilitating
assessment of treatment effectiveness. This documentation method provides consistent, measurable
data while respecting the patient's individual experience-3-6.
Question 4
When communicating with older children and teenagers, you should be sensitive to their:
Answer: Need for confidentiality and privacy.
Rationale: Adolescents are often reluctant to share personal health information, particularly if
they fear it will be disclosed to parents or guardians without their consent. Providers should clearly
communicate respect for confidentiality (within legal and safety boundaries) to establish trust and
encourage honest disclosure. This is essential for obtaining a complete health history and addressing
sensitive issues such as sexual health, substance use, and mental health concerns-3-6.
Question 5
J.M. has been seen in your clinic for 5 years. She presents today with signs and symptoms of
acute sinusitis. The type of history that is warranted is a(n) ______ history.
Answer: Focused