Chapter 05
MULTIPLE CHOICE
1. During the course of the interview, you should:
a. take no notes of any kind.
b. take brief written notes.
c. take detailed written notes.
d. repeat pertinent comments into a Dictaphone.
e. interrupt the interview to formulate your thoughts.
ANS: B
During the interviewing process, it is important to maintain eye contact with the patient and to
spend as little time as possible looking at your notes, so brief written notes are more practical.
Later you can go back and formulate a well-versed history by linking all the pieces together.
TOP: Discipline: Behavioral Science MSC: Organ System: General
2. Subjective and symptomatic data are:
a. documented in your assessment.
b. not mentioned in the legal chart.
c. placed in the history sections.
d. recorded with the examination technique.
e. documented with the findings.
ANS: C NURSINGTB.COM
Subjective data, as well as symptomatic data, should not be part of the physical examination
findings; rather, their documentation is appropriate for the history portion.
TOP: Discipline: Behavioral Science MSC: Organ System: General
3. The quality of a symptom, such as pain, is subjective information that should be:
a. deferred until the cause is determined.
b. described in the history using a 0 to 10 scale.
c. placed in the past medical history section.
d. placed in the history with objective data.
e. interpreted in light of your physical findings.
ANS: B
Pain is subjective, and only the patient can rate the perceived severity. Pain, therefore, should
be recorded in the history using a 0 to 10 scale.
TOP: Discipline: Behavioral Science MSC: Organ System: General
4. Drawing of stick figures is most useful to:
a. compare findings in the extremities.
b. demonstrate radiation of pain.
c. indicate organ enlargement.
d. indicate mobility of masses.
, e. indicate consistency of lymph nodes.
ANS: A
Simple drawings, such as stick figures, are more practical illustrations for findings in the
extremities. Radiation of pain, organ enlargement, consistency of lymph nodes, and mobility
of masses would not be adequately described by such simple drawings.
TOP: Discipline: Behavioral Science MSC: Organ System: General
5. Which of he follo ing is an e ample of a problem req iring recording on he pa ien s
problem list?
a. Common age variations
b. Expected findings
c. Findings of unknown origin
d. Minor variations
e. Only findings that have a clear etiology
ANS: C
Any problem is worth noting on the patient problem list even if the etiology or significance is
unknown. Common age variations, expected findings, and minor variations within normal
limits should not be classified as problems.
TOP: Discipline: Behavioral Science MSC: Organ System: General
6. Differential diagnoses belong in the:
a. history.
b. physical examination.
c. assessment. NURSINGTB.COM
d. plan.
e. laboratory data.
ANS: C
Differential diagnoses for problems that have not been diagnosed are placed in the assessment
category for each problem. The differentials are prioritized, and contributing factors are
identified.
TOP: Discipline: Behavioral Science MSC: Organ System: General
7. When recording assessments during the construction of the problem-oriented medical record,
the examiner should:
a. combine all data into one assessment.
b. create an assessment for each problem on the problem list.
c. create an assessment for every abnormal physical finding.
d. create an assessment for every symptom presented in the history.
e. create an assessment for each abnormal laboratory finding.
ANS: B
After the examiner has a list of problems constructed, an assessment is made for each unique
problem.
TOP: Discipline: Behavioral Science MSC: Organ System: General
MULTIPLE CHOICE
1. During the course of the interview, you should:
a. take no notes of any kind.
b. take brief written notes.
c. take detailed written notes.
d. repeat pertinent comments into a Dictaphone.
e. interrupt the interview to formulate your thoughts.
ANS: B
During the interviewing process, it is important to maintain eye contact with the patient and to
spend as little time as possible looking at your notes, so brief written notes are more practical.
Later you can go back and formulate a well-versed history by linking all the pieces together.
TOP: Discipline: Behavioral Science MSC: Organ System: General
2. Subjective and symptomatic data are:
a. documented in your assessment.
b. not mentioned in the legal chart.
c. placed in the history sections.
d. recorded with the examination technique.
e. documented with the findings.
ANS: C NURSINGTB.COM
Subjective data, as well as symptomatic data, should not be part of the physical examination
findings; rather, their documentation is appropriate for the history portion.
TOP: Discipline: Behavioral Science MSC: Organ System: General
3. The quality of a symptom, such as pain, is subjective information that should be:
a. deferred until the cause is determined.
b. described in the history using a 0 to 10 scale.
c. placed in the past medical history section.
d. placed in the history with objective data.
e. interpreted in light of your physical findings.
ANS: B
Pain is subjective, and only the patient can rate the perceived severity. Pain, therefore, should
be recorded in the history using a 0 to 10 scale.
TOP: Discipline: Behavioral Science MSC: Organ System: General
4. Drawing of stick figures is most useful to:
a. compare findings in the extremities.
b. demonstrate radiation of pain.
c. indicate organ enlargement.
d. indicate mobility of masses.
, e. indicate consistency of lymph nodes.
ANS: A
Simple drawings, such as stick figures, are more practical illustrations for findings in the
extremities. Radiation of pain, organ enlargement, consistency of lymph nodes, and mobility
of masses would not be adequately described by such simple drawings.
TOP: Discipline: Behavioral Science MSC: Organ System: General
5. Which of he follo ing is an e ample of a problem req iring recording on he pa ien s
problem list?
a. Common age variations
b. Expected findings
c. Findings of unknown origin
d. Minor variations
e. Only findings that have a clear etiology
ANS: C
Any problem is worth noting on the patient problem list even if the etiology or significance is
unknown. Common age variations, expected findings, and minor variations within normal
limits should not be classified as problems.
TOP: Discipline: Behavioral Science MSC: Organ System: General
6. Differential diagnoses belong in the:
a. history.
b. physical examination.
c. assessment. NURSINGTB.COM
d. plan.
e. laboratory data.
ANS: C
Differential diagnoses for problems that have not been diagnosed are placed in the assessment
category for each problem. The differentials are prioritized, and contributing factors are
identified.
TOP: Discipline: Behavioral Science MSC: Organ System: General
7. When recording assessments during the construction of the problem-oriented medical record,
the examiner should:
a. combine all data into one assessment.
b. create an assessment for each problem on the problem list.
c. create an assessment for every abnormal physical finding.
d. create an assessment for every symptom presented in the history.
e. create an assessment for each abnormal laboratory finding.
ANS: B
After the examiner has a list of problems constructed, an assessment is made for each unique
problem.
TOP: Discipline: Behavioral Science MSC: Organ System: General
