solution
When writing a SOAP note, the nurse practitioner is aware that "A" represents
The diagnosis
When reading a healthcare record you see the following notation: Patient states "I have
had a runny nose and a cough for 1 week now" This is an example of:
Chief complaint
Which of the following is an appropriate recording of the subjective information provided
by a patient?
"grabbing" chest pain for 2 hours
You receive results from the laboratory, a metabolic panel and a CBC. Where should
that information appear in the SOAP note?
Objective
The nurse asks "Mr. S. tell me what you do when your headaches occur," with this
question you are seeking information about:
Aggravating and relieving factors
What is the best terminology to describe significant symptoms associated with each
area of the patient's body?
Review of systems
Mrs. Ellis is being seen for a routine physical examination. She is a college graduate
and president of a research firm. She attends the local Methodist church weekly. She
has adequate health insurance. Most of this information belongs in her:
Personal and social history
Mr. S complains of a headache. During the history, he mentions his use of alcohol and
street drugs. Where is the most appropriate place for this information?
Social history
You are a nurse practitioner in a busy primary care practice, when should you ask your
patient about substance use?
A) when prescribing medication
B) At an episodic visit
C) At the patient's annual health assessment
D) All of the above
All of the above
It is important to ask your patient about their sexual history. Why? Select all that apply.
1. To assess their risk for potential pregnancy in females of childbearing age
2. It is important to know their sexual preferences
3. So that you can provide patient centered sex education
4. To learn their potential risk for sexually transmitted infection
Documentation of the general survey includes
Posture, gait, motor activity and personal hygiene
The normal appearance of the tympanic membrane is
Pearly grey with a visible cone of light shining downward & forward from center
While undergoing the Rinne test for air conduction (AC) and bone conduction (BC),
normal findings would reveal that
, AC is greater than BC
Which of the following describes a normal thyroid examination finding? Select all that
apply.
1. nonpalpable
2. Slightly palpable, smooth, symmetrical
Macule
Flat, non-palpable <1cm lesion
Common mole (nevi)
Hyperpigmented papule 0.75 cm
Patch
flat >1cm lesion
Bullae
fluid-filled, well circumscribed lesion >1com
Fissure
narrow linear crack into epidermis, exposing dermis
Vesicle
fluid-filled, well circumscribed lesion <5mm
The most lethal skin cancer is
melanoma
A 4 by 3 cm, well circumscribed, rough, elevated area of skin is an example of a
plaque
The mental status exam consists of assessment of a patient's appearance and
behavior, speech and language, mood, thoughts and perceptions and cognitive
function. By questioning orientation to time, person, and place, recent and remote
memory, you are assessing
Cognitive function
You are seeing a 37 year old female that you suspect is suffering from depression and
you are concerned about her risk of suicide. Which of the following findings is of
greatest concern that would cause you to recommend immediate hospitalization or
referral to the emergency room or crisis for further evaluation
History of previous suicide attempt with current intent and means
What is responsible for the inspiratory splitting of S2
Closure of the aortic, then pulmonic valves
When recording results of heart murmurs, it is important to include
quality, pitch, location, grade
A grade 2 murmur is best described as
Quiet, heard immediately after placing stethoscope on the chest
A 23-year old optical assistant comes to your office for evaluation of fatigue. As part of
your physical examination, you listen to her heart and hear a Grade 2 murmur only at
the cardiac apex. Which valve is most likely to be involved, based on the location of the
murmur?
Mitral
You listen to the chest and hear a murmur that falls between S1 and S2. This murmur is
identified as
a systolic murmur
Jugular venous pressure is considered elevated when: