Exam 1 7470
A survey of mobility and activities of daily living is part of a/an:
a. Review of systems
b. Functional assessment
c. History of present illness
d. Social history - correct answer ✔b. Functional assessment
Collecting History and Interviewing Techniques, slide 14
Functional assessment is an evaluation of mobility, ADL's and an overall risk
assessment.
Which of the following statements are acceptable under the HIPPA Privacy
Rule?
a. Discussing the care of a patient with another NP over lunch in the break
room.
b. Discussing a patient's assessment, diagnosis, plan of care and prognosis
with the Human Resources Director of the patient's employer.
c. The Nurse Practitioner communicating with their supervising primary care
physician about a patient's assessment, diagnosis and plan of care.
d. Discussing the care of a patient with a student and the student's instructor
lunch in the hall prior to going into room. - correct answer ✔c. The Nurse
Practitioner communicating with their supervising primary care physician
about a patient's assessment, diagnosis and plan of care.
Though this physician may not know the patient, the NP and through NP the
supervising physician has a relationship with the patient. Consequently, this is
not a violation of privacy
,When collecting the history of present illness, it is important to get information
about the quality and character of the symptoms. A useful way to do this is to
use:
a. OLDCARTS
b. OPQRST
c. COLDSPA
d. All of the above - correct answer ✔d. All of the above
Some pneumonic to help you remember what to ask...COLDSPA is one in
Dains book, OPQRST is mentioned in your Bates' book. I use OLDCARTS:
Onset, location, duration, characteristics, aggravating factors, relieving
factors, timing, severity
Assessment: Collecting the History and Interveiwing Techniques lecutre, slide
8
What is the purpose of the review of systems (ROS)?
a. To document more information in the physical exam portion of the medical
record.
b. To make the patient talk more cause in order to reveal the environmental
and social context of the patient's problems.
c. To evaluate the patient's social and personal history.
d. To do a detailed review of possible complaints in each of the body systems,
looking for other information that may not have come out in the HPI. - correct
answer ✔d. To do a detailed review of possible complaints in each of the
body systems, looking for other information that may not have come out in the
HPI.
Purpose is to uncover symptoms that may have not been discussed in the HPI
that could influence your decisions.
,Assessment: Collecting the History and Interviewing Techniques, slide 13
What is true of the Snellen Chart?
a. The patient should be positioned 20 feet from the Snellen chart.
b. There are different types of Snellen charts based on literacy and age.
c. Snellen charts are used to assess visual acuity.
d. All of the above. - correct answer ✔d. All of the above.
Examination Techniques and Equipment lecture
Snellen charts come in letters, animal shapes, and hand held. The patient
should be placed 20 feet away from the chart. It is used to test visual acuity.
A comprehensive health history is an essential guide for the rest of the
examination, but not if the patient cannot communicate it clearly. There are
any number of reasons for this lack of clear communication: age, trauma,
language difficulties, or simply that the patient is uncooperative.
If the data is apparently unclear or may be inaccurate, what is the best
approach to documenting the history?
a. Document the history in the patient's own words, but note that the
information may be unreliable and document specific concerns.
b. If the patient's history is not clear or inaccurate, do not document it.
c. Document the history in the patient's own words and interpret the meaning
whenever it is unclear.
d. After gathering information on the symptoms, the practitioner should
interpret and document the history in his/her own interpretation. - correct
answer ✔a. Document the history in the patient's own words, but note that
the information may be unreliable and document specific concerns.
, Documenting and Recording lecture, slide 4
Document what the patient says, not what the practitioner interprets.
What is TRUE regarding examination techniques?
a. If your patient is especially modest, performing the respiratory examination
over clothing may assist to alleviate anxiety.
b. Inspection can be done throughout the history taking process and during
the physical examination.
c. Direct percussion involves using the fingers of one hand to strike the finger
of the opposite hand to elicit a sound.
d. The diaphragm of the stethoscope is most useful in the assessment of low-
pitched sounds. - correct answer ✔b. Inspection can be done throughout the
history taking process and during the physical examination.
All auscultation should be done against the skin and not over clothes. Direct
percussion involves stiking the hand directly against the skin of the patient.
The bell of the stethoscope is used to assess dull,low pitched sounds.
What example of skin documentation illustrates a vague or non-descriptive
term?
a. "Patient's muscle strength is 5/5 in all extremities."
b. "Patient's skin is warm, dry, and intact."
c. "Patient's capillary refill is within normal limits."
d. "Patient has a grade 2/6 systolic murmur." - correct answer ✔c. "Patient's
capillary refill is within normal limits."
Documenting and Recording Information lecture
A survey of mobility and activities of daily living is part of a/an:
a. Review of systems
b. Functional assessment
c. History of present illness
d. Social history - correct answer ✔b. Functional assessment
Collecting History and Interviewing Techniques, slide 14
Functional assessment is an evaluation of mobility, ADL's and an overall risk
assessment.
Which of the following statements are acceptable under the HIPPA Privacy
Rule?
a. Discussing the care of a patient with another NP over lunch in the break
room.
b. Discussing a patient's assessment, diagnosis, plan of care and prognosis
with the Human Resources Director of the patient's employer.
c. The Nurse Practitioner communicating with their supervising primary care
physician about a patient's assessment, diagnosis and plan of care.
d. Discussing the care of a patient with a student and the student's instructor
lunch in the hall prior to going into room. - correct answer ✔c. The Nurse
Practitioner communicating with their supervising primary care physician
about a patient's assessment, diagnosis and plan of care.
Though this physician may not know the patient, the NP and through NP the
supervising physician has a relationship with the patient. Consequently, this is
not a violation of privacy
,When collecting the history of present illness, it is important to get information
about the quality and character of the symptoms. A useful way to do this is to
use:
a. OLDCARTS
b. OPQRST
c. COLDSPA
d. All of the above - correct answer ✔d. All of the above
Some pneumonic to help you remember what to ask...COLDSPA is one in
Dains book, OPQRST is mentioned in your Bates' book. I use OLDCARTS:
Onset, location, duration, characteristics, aggravating factors, relieving
factors, timing, severity
Assessment: Collecting the History and Interveiwing Techniques lecutre, slide
8
What is the purpose of the review of systems (ROS)?
a. To document more information in the physical exam portion of the medical
record.
b. To make the patient talk more cause in order to reveal the environmental
and social context of the patient's problems.
c. To evaluate the patient's social and personal history.
d. To do a detailed review of possible complaints in each of the body systems,
looking for other information that may not have come out in the HPI. - correct
answer ✔d. To do a detailed review of possible complaints in each of the
body systems, looking for other information that may not have come out in the
HPI.
Purpose is to uncover symptoms that may have not been discussed in the HPI
that could influence your decisions.
,Assessment: Collecting the History and Interviewing Techniques, slide 13
What is true of the Snellen Chart?
a. The patient should be positioned 20 feet from the Snellen chart.
b. There are different types of Snellen charts based on literacy and age.
c. Snellen charts are used to assess visual acuity.
d. All of the above. - correct answer ✔d. All of the above.
Examination Techniques and Equipment lecture
Snellen charts come in letters, animal shapes, and hand held. The patient
should be placed 20 feet away from the chart. It is used to test visual acuity.
A comprehensive health history is an essential guide for the rest of the
examination, but not if the patient cannot communicate it clearly. There are
any number of reasons for this lack of clear communication: age, trauma,
language difficulties, or simply that the patient is uncooperative.
If the data is apparently unclear or may be inaccurate, what is the best
approach to documenting the history?
a. Document the history in the patient's own words, but note that the
information may be unreliable and document specific concerns.
b. If the patient's history is not clear or inaccurate, do not document it.
c. Document the history in the patient's own words and interpret the meaning
whenever it is unclear.
d. After gathering information on the symptoms, the practitioner should
interpret and document the history in his/her own interpretation. - correct
answer ✔a. Document the history in the patient's own words, but note that
the information may be unreliable and document specific concerns.
, Documenting and Recording lecture, slide 4
Document what the patient says, not what the practitioner interprets.
What is TRUE regarding examination techniques?
a. If your patient is especially modest, performing the respiratory examination
over clothing may assist to alleviate anxiety.
b. Inspection can be done throughout the history taking process and during
the physical examination.
c. Direct percussion involves using the fingers of one hand to strike the finger
of the opposite hand to elicit a sound.
d. The diaphragm of the stethoscope is most useful in the assessment of low-
pitched sounds. - correct answer ✔b. Inspection can be done throughout the
history taking process and during the physical examination.
All auscultation should be done against the skin and not over clothes. Direct
percussion involves stiking the hand directly against the skin of the patient.
The bell of the stethoscope is used to assess dull,low pitched sounds.
What example of skin documentation illustrates a vague or non-descriptive
term?
a. "Patient's muscle strength is 5/5 in all extremities."
b. "Patient's skin is warm, dry, and intact."
c. "Patient's capillary refill is within normal limits."
d. "Patient has a grade 2/6 systolic murmur." - correct answer ✔c. "Patient's
capillary refill is within normal limits."
Documenting and Recording Information lecture
