Question 1
When recording assessments during the construction of the problem-oriented medicalrecord, the
examiner should:
Response Once the examiner has a list of problems constructed, then anassessment is made for
Feedback: each unique problem.
Question 2
What finding is unique to the documentation of a physical examination of an infant?
Response The size & characteristic of the fontanel are unique & important in the assessment of
Feedback: an infant. Data on liver span, prostate size, thyroid position,& visual acuity are adult
assessment findings.
Question 3
The quality of a symptom, such as pain, is subjective information that should be:
Response Pain is subjective & only the patient can rate the perceived severity. Pain,therefore,
Feedback: should be recorded the history using a 1-to-10 scale.
Question 4
When communicating with older children & teenagers, you should be sensitive to their:
Response Adolescents are usually reluctant to talk; therefore, the provider shouldclearly
Feedback: communicate a respect for their confidentiality.
Question 5
J.M. has been seen in your clinic for 5 years. She presents today with signs & symptoms of acute
sinusitis. The type of history that is warranted is a(n) history.
Response If the patient is well known or if you have been seeing the patient for the same
Feedback: problem over time, a focused history is appropriate.
Question 6
An example of a complementary care modality is:
Response Complementary care includes acupuncture, aromatherapy, therapeutictouch, &
Feedback: herbal medications.
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, Question 7
Mr. D. complains of a headache. During the history, he mentions his use of alcohol &illicit drugs.
This information would most likely belong in the:
Response Habits are included within the personal &social
Feedback: history.
Question 8
In issues surrounding ethical decision making, beneficence refers to the
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