WGU D117 Advanced Health Assessment
Documentation Form Examination 2026–2027 |
Comprehensive 150 -Question Practice Test with
Answers & Rationales| Free Pdf Access
Question 1
A patient reports: "My chest pain started yesterday around 3 PM. It's a sharp pain in the
middle of my chest. It gets worse when I walk up stairs and feels better when I sit still."
This statement is best documented in which part of the health history?
A) Past Medical History
B) Family History
C) History of Present Illness
D) Review of Systems
Correct Answer: C
The History of Present Illness (HPI) documents the patient's chief complaint using
OLDCARTS (Onset, Location, Character, Aggravating/Relieving factors). This patient
statement includes onset (yesterday 3 PM), location (middle of chest), character (sharp),
aggravating (stairs), and relieving (sitting still). Proper HPI documentation requires
capturing all OLDCARTS elements to support clinical reasoning .
Question 2
A nurse practitioner is writing a note for a patient with abdominal pain. Which entry
represents the BEST example of documented "Objective" data?
,A) "The patient states the pain is a 7/10."
B) "The patient appears anxious and is sweating heavily."
C) "Abdomen soft, non-tender to palpation in all four quadrants; bowel sounds present
x4."
D) "Patient likely has gastroenteritis versus cholecystitis."
Correct Answer: C
Objective data consists of measurable, observable, and verifiable findings obtained during
the physical exam (inspection, palpation, auscultation). Patient statements are subjective,
and diagnoses belong in the Assessment section. Physical exam findings must be
documented precisely as observed .
Question 3
A patient reports, "My father died of a heart attack at age 45, my mother has diabetes,
and my sister was diagnosed with breast cancer last year." This information belongs in
which section?
A) Past Medical History
B) Social History
C) Family History
D) Review of Systems
Correct Answer: C
Family History documents genetic predispositions, hereditary conditions, and age of onset
of diseases in first- and second-degree relatives. This information guides screening
recommendations, such as early cardiac screening for the patient with paternal early MI,
and risk assessment for hereditary cancer syndromes .
,Question 4
What does the acronym PQRST stand for in health assessment documentation?
A) Precipitating factors, Quality, Radiation, Severity, Timing
B) Pain, Quality, Relief, Severity, Time
C) Provocation, Quality, Region, Severity, Treatment
D) Precipitating, Quantity, Radiation, Symptoms, Timing
Correct Answer: A
PQRST stands for Precipitating factors, Quality, Radiation, Severity, and Timing. This
mnemonic is used to assess pain or other symptoms in a comprehensive and systematic
manner during the symptom analysis portion of the health history .
Question 5
Under the Joint Commission's "Do Not Use" list, which abbreviation is prohibited
because it can be mistaken for "IV" or "10"?
A) QD
B) MS
C) U
D) QHS
Correct Answer: C
"U" for units is prohibited because poor handwriting can lead to misinterpretation as "0,"
"4," or "IV." The correct documentation is to write the word "units" in full. This abbreviation
error has resulted in medication errors involving insulin and heparin, making strict
adherence to the "Do Not Use" list essential for patient safety .
, Question 6
A patient believes that strangers on the bus are FBI agents following them. This is
documented as:
A) Illusion
B) Hallucination
C) Delusion
D) Obsession
Correct Answer: C
A delusion is a fixed, false belief not shared by the patient's culture. This is specifically a
persecutory delusion. Delusions are a hallmark of psychotic disorders. Illusions are
misinterpretations of real stimuli, while hallucinations are sensory perceptions without
external stimuli .
Question 7
During a mental status exam, "mood" is defined as:
A) The observed emotional expression
B) The patient's subjective report of emotion
C) The intensity of emotional response
D) The appropriateness of emotion to context
Correct Answer: B
Mood is defined as the patient's subjective report of emotion. Affect is what the examiner
observes objectively. Mood should be documented using the patient's own words when
possible to ensure accurate representation of the patient's internal experience .
Documentation Form Examination 2026–2027 |
Comprehensive 150 -Question Practice Test with
Answers & Rationales| Free Pdf Access
Question 1
A patient reports: "My chest pain started yesterday around 3 PM. It's a sharp pain in the
middle of my chest. It gets worse when I walk up stairs and feels better when I sit still."
This statement is best documented in which part of the health history?
A) Past Medical History
B) Family History
C) History of Present Illness
D) Review of Systems
Correct Answer: C
The History of Present Illness (HPI) documents the patient's chief complaint using
OLDCARTS (Onset, Location, Character, Aggravating/Relieving factors). This patient
statement includes onset (yesterday 3 PM), location (middle of chest), character (sharp),
aggravating (stairs), and relieving (sitting still). Proper HPI documentation requires
capturing all OLDCARTS elements to support clinical reasoning .
Question 2
A nurse practitioner is writing a note for a patient with abdominal pain. Which entry
represents the BEST example of documented "Objective" data?
,A) "The patient states the pain is a 7/10."
B) "The patient appears anxious and is sweating heavily."
C) "Abdomen soft, non-tender to palpation in all four quadrants; bowel sounds present
x4."
D) "Patient likely has gastroenteritis versus cholecystitis."
Correct Answer: C
Objective data consists of measurable, observable, and verifiable findings obtained during
the physical exam (inspection, palpation, auscultation). Patient statements are subjective,
and diagnoses belong in the Assessment section. Physical exam findings must be
documented precisely as observed .
Question 3
A patient reports, "My father died of a heart attack at age 45, my mother has diabetes,
and my sister was diagnosed with breast cancer last year." This information belongs in
which section?
A) Past Medical History
B) Social History
C) Family History
D) Review of Systems
Correct Answer: C
Family History documents genetic predispositions, hereditary conditions, and age of onset
of diseases in first- and second-degree relatives. This information guides screening
recommendations, such as early cardiac screening for the patient with paternal early MI,
and risk assessment for hereditary cancer syndromes .
,Question 4
What does the acronym PQRST stand for in health assessment documentation?
A) Precipitating factors, Quality, Radiation, Severity, Timing
B) Pain, Quality, Relief, Severity, Time
C) Provocation, Quality, Region, Severity, Treatment
D) Precipitating, Quantity, Radiation, Symptoms, Timing
Correct Answer: A
PQRST stands for Precipitating factors, Quality, Radiation, Severity, and Timing. This
mnemonic is used to assess pain or other symptoms in a comprehensive and systematic
manner during the symptom analysis portion of the health history .
Question 5
Under the Joint Commission's "Do Not Use" list, which abbreviation is prohibited
because it can be mistaken for "IV" or "10"?
A) QD
B) MS
C) U
D) QHS
Correct Answer: C
"U" for units is prohibited because poor handwriting can lead to misinterpretation as "0,"
"4," or "IV." The correct documentation is to write the word "units" in full. This abbreviation
error has resulted in medication errors involving insulin and heparin, making strict
adherence to the "Do Not Use" list essential for patient safety .
, Question 6
A patient believes that strangers on the bus are FBI agents following them. This is
documented as:
A) Illusion
B) Hallucination
C) Delusion
D) Obsession
Correct Answer: C
A delusion is a fixed, false belief not shared by the patient's culture. This is specifically a
persecutory delusion. Delusions are a hallmark of psychotic disorders. Illusions are
misinterpretations of real stimuli, while hallucinations are sensory perceptions without
external stimuli .
Question 7
During a mental status exam, "mood" is defined as:
A) The observed emotional expression
B) The patient's subjective report of emotion
C) The intensity of emotional response
D) The appropriateness of emotion to context
Correct Answer: B
Mood is defined as the patient's subjective report of emotion. Affect is what the examiner
observes objectively. Mood should be documented using the patient's own words when
possible to ensure accurate representation of the patient's internal experience .
