NBRC Exam - Patient Assessment - Module A - Patient Assessment Questions With Complete Solutions

What do you review in the patient's history? correct answer: - History - Admission data - Progress notes - Diagnosis - Respiratory care orders - Medication history - Do not resuscitate (DNR) status and advance directives - Social history What do you note in patient history? correct answer: 1. Date of history taking 2. Patient data: name, age, gender, race, and occupation 3. Primary complaints 4. Secondary complaints 5. Present illness history and symptoms 6. Family history 7. Medical history of cardiopulmonary disease(s), including smoking history, cough, sputum production, allergies, and activities of daily living 8. Review of body systems The attending physician writes up his or her key findings and how they are related to the reason the patient was admitted to the hospital. What is this information called? correct answer: Admission data What do you do it the physician notes a change in the patient's care plan? correct answer: Check for new patient care orders True or false: You should review the physician's, nurse's, and respiratory therapist's patient progress notes before seeing the patient and beginning the therapeutic procedure. correct answer: True When reviewing progress notes, what is the respiratory therapist looking for? correct answer: Any cardiopulmonary or other organ-system changes that will have an impact on the patient's ability to take the treatment. After the medical history, physical exam, and laboratory tests are completed, the patient will be placed in one of four diagnostic categories. What are these categories? correct answer: - Crisis/acute onset of illness - Intermittent but repeated illness - Progressive worsening - Mixed patterns/multiple problems What must physician orders have? correct answer: - Patient's name - The date - The time - Complete and proper orders for each therapeutic procedure - The physician's signature How does the respiratory therapist confirm incomplete, improper, or questionable orders? correct answer: Call the physician What medications are important to note when reviewing medication history? correct answer: Any medications used to help manage cardiovascular, renal, or neurological problems that may affect the patient's respiratory status. Where should a DNR be posted? correct answer: - Electronic medical record - Patient's room