Deck 28: Patient Assessment

Question 1

The medical assistant is responsible for performing the systems review.

Answer 1

False

Question 2

The best method of ensuring that the patient understands a patient education intervention is to have the patient repeat back the details learned.

Answer 2

True

Question 3

Documenting that the patient reports a headache of 3 days' duration is part of the objective data in the POMR record.

Answer 3

False

Question 4

Congruence is achieved when the communicator's words and body language are delivering the same message.

Question 5

Issues of privacy are important to adolescent patients.

Question 6

The initial diagnosis made by the physician after completion of the physical examination is the differential diagnosis.

Question 7

A patient's lifestyle factors would be included in the family history section of the medical history.

Question 8

Research on the significance of body language indicates that 50% of the message received by patients is interpreted from the caregiver's nonverbal language.

Question 9

Children should always be given a choice whether to take their medication.

Question 10

Providing patients with automatic reassurance when they express a concern is part of a therapeutic relationship.

Question 11

When conducting a patient interview, the medical assistant should sit behind a desk with arms crossed and wait for the patient to establish eye contact.

Question 12

The chief complaint may also be called the patient's present illness.

Question 13

It is acceptable to skip lines when documenting to give the physician room to enter a note after the patient has been seen.

Question 14

Value systems are learned beliefs and behaviors that can affect therapeutic relationships.

Question 15

Gathering details about a patient's use of over-the-counter medications is not necessary during a patient interview.

Question 16

A sign is a patient-reported indication of disease.

Question 17

If a patient displays obnoxious and rude behavior while the medical history is taken, the medical assistant should include a comment about this behavior in the documentation.

Question 18

An example of an objective sign of disease is the patient's reported level of pain.

Question 19

The most effective distance between a patient and the medical assistant conducting an interview is approximately 2 to 3 feet.

Question 20

A patient interview may be conducted in a quiet corner of the waiting room.

Question 21

Asian patients may have difficulty maintaining eye contact during an interview.

Question 22

When communicating with a sick child, it is important to direct all questions toward the child's parent.

Question 23

The size and shape of a wound would be included in the assessment section of SOAP documentation.

Question 24

The SOMR begins with a list of the patient's health problems.

Question 25

Which of the following factors is likely to have the most influence on the accuracy and completeness of the information obtained from the patient during the medical history?

A)The comfort of the chairs in the meeting area
B)The medical assistant's ability to take complete and detailed notes
C)The privacy of the area in which the interview takes place
D)The efficiency of the medical assistant in conducting the interview

Question 26

When the medical assistant asks the patient about the duration of the symptoms, the question is about when the symptoms began.

Question 27

Giving advice when it is requested by a patient is an effective way of displaying concern.

Question 28

If the medical assistant is caring for an aging patient who has difficulty hearing, he or she should ignore the patient and direct the interaction toward a family member.

Question 29

Which of the following actions is not usually appropriate for showing interest in patients?

A)Hugging them reassuringly when greeting them
B)Leaning toward them to show that you are listening to them
C)Moving in a confident manner as you work with them
D)Using a friendly tone of voice when speaking to them

Question 30

Subjective data include the patient's report of injuries and resultant pain level.

Question 31

The easiest way to get specific information from the patient is to use open-ended questions.

Question 32

A 6-year-old child who refuses to leaver her mother's lap during a physical examination is displaying regression.

Question 33

While you are taking the medical history of a new patient, the patient mentions having occasional headaches that are quite painful.What is the best way for you to proceed with the interview?

A)Express concern and note this information in writing.
B)Ask the patient a direct question about the pain.
C)Reassure the patient that it is probably nothing serious.
D)Ask the patient an open-ended question about the headaches.

Question 34

Progress notes in the POMR include the use of SOAPE documentation.

Question 35

What does it mean when medical assistants display empathy when dealing with patients?

A)They feel sorry for patients who have serious health problems.
B)They are able to hear what patients say without judging the content.
C)They can detach themselves emotionally from the problems of their patients.
D)They truly like and care about each of their patients.

Question 36

A patient who accuses the medical assistant of being short tempered when the patient has just screamed at the medical assistant about a bill is displaying the defense mechanism of projection.

Question 37

It is important for the medical assistant to keep arms and legs crossed during an interview to communicate authority to the patient.

Question 38

Restatement is a valuable active listening technique, because it acknowledges the emotions displayed by the patient during the interview.

Question 39

The section of the medical history that helps uncover existing or potential health problems is called the:

A)database
B)past history
C)social history
D)systems review

Question 40

The physician's decision to refer a patient to a dietician is documented under the assessment category of SOAP records.

Question 41

Which of the following is a closed question or statement?

A)"Tell me about your headaches."
B)"Does your head hurt?"
C)"How are you feeling?"

Question 42

Which of the following includes insurance information?

A)Family history
B)Past history
C)Social history
D)Database
E)ROS

Question 43

Which of the following involves asking a question or summarizing a patient's thoughts?

A)Restatement
B)Clarification
C)Reflection

Question 44

During the physical examination, the patient reports a continual ache in the right elbow.This information is called a(n):

A)functional problem
B)objective finding
C)sign
D)symptom

Question 45

Information that you gather from a patient interview is considered:

A)subjective
B)objective
C)assessment
D)evaluation

Question 46

Which of the following questions or statements would encourage the patient to continue to communicate?

A)"Does your arm hurt?"
B)"Did you hurt yourself?"
C)"Tell me about how your arm feels right now."
D)"Do you have a family history of arthritis?"

Question 47

Which statement best describes what it means to have good rapport with patients?

A)You use language they understand.
B)They respect you as a professional.
C)You have smooth, pleasant relationships with them.
D)You are polite and punctual.

Question 48

Which of the following involves repeating or paraphrasing the patient's comments?

A)Restatement
B)Clarification
C)Reflection

Question 49

Which of the following sections of the medical record includes the physical examination findings?

A)Family history
B)Past history
C)Social history
D)Database
E)ROS

Question 50

Which of the following includes the patient's dietary habits, smoking history, and alcohol consumption?

A)Family history
B)Past history
C)Social history
D)Database
E)ROS

Question 51

Which of the following includes childhood diseases?

A)Family history
B)Past history
C)Social history
D)Database
E)ROS

Question 52

Why would you take a patient's vital signs at both the beginning and end of the office visit for a physical examination?

A)To evaluate the effectiveness of treatment given during the visit
B)Because the patient was anxious on arrival at the office
C)To reassure the patient that he or she is receiving adequate care
D)To ensure the accuracy of the procedures by double-checking the results

Question 53

What is the best way to obtain specific information about a patient when taking the medical history?

A)Summarize the facts revealed by the patient when answering questions.
B)Ask direct questions that can be answered briefly.
C)Restate what the patient has said to check the accuracy of what was heard.
D)Encourage the patient to explain the answers fully.

Question 54

A medical assistant who is a good listener consistently:

A)provides repeated assurances
B)provides feedback to clarify the patient's message
C)interrupts the patient to gather more details
D)limits the amount of time spent on each interview

Question 55

Which of the following includes demographic information?

A)Family history
B)Past history
C)Social history
D)Database
E)ROS

Question 56

Which of the following is an open-ended question or statement?

A)"How old are you?"
B)"Do you smoke?"
C)"What brings you to the office today?"

Question 57

Which of the following involves stating an observation or recognition of a patient's feeling?

A)Restatement
B)Clarification
C)Reflection

Question 58

Which medical record system has a standard format that makes it easy to read and audit?

A)Chronologic
B)Problem oriented
C)Progress note
D)Source oriented

Question 59

The medical assistant is responsible for documenting all of the following information except the:

A)review of systems
B)family history
C)social history
D)allergies

Question 60

Objective data include which of the following?

A)Complaints of pain
B)Social history
C)Blood pressure recordings
D)Past medical history

Question 61

When a verbal message matches the sender's nonverbal body language, the message is considered __________.

Question 62

During a physical examination the patient reports problems with speech and balance.These signs indicate a problem with which system?

A)Respiratory
B)Neurologic
C)Cardiovascular
D)Lymph

Question 63

Sam Hernandez, a 17-year-old patient with burning upon urination, has just been told he has an STD.He had suspected that he had gonorrhea, but he states, "The test must be wrong.I just have a bladder infection." He is displaying which defense mechanism?

A)Suppression
B)Denial
C)Regression
D)Sublimation

Question 64

Sally Tipoke, age 17, is scheduled for her first Pap smear today.She appears anxious and scared.Choose the medical assistant's most appropriate statement.

A)"There's no need to worry about the test.Dr.Smith never hurts anyone."
B)"You look worried about the exam.Can I answer any questions?"
C)"If you just think about something positive, it will be over before you know it."
D)"Dr.Smith expects you to stay still during the exam."

Question 65

__________ are subjective reports given by patients about how they feel with a particular health problem.

Question 66

Abnormalities in the cardiovascular system that are discovered during an ROS include:

A)deformity of the chest
B)hypertension and leg cramps
C)deviated septum
D)jaundice

Question 67

Which of the following factors are part of the linear communication model?

A)Listener, channel, message
B)Sender, listener, feedback
C)Sender, channel, receiver, feedback
D)Channel, message, feedback, listener

Question 68

The __________ of the interview should summarize the information the medical assistant learned while communicating with the patient and should outline patient expectations of care.

Question 69

During the __________ phase of the interview, medical assistants should introduce themselves and state the purpose of the interview.

Question 70

Helen Conrad, age 54, was recently diagnosed with epilepsy.She is very upset about the news.A therapeutic interaction might be:

A)"Look on the bright side; things could be worse."
B)"The doctor will prescribe medication, which will probably prevent most seizures."
C)Distract the patient by discussing the weather.
D)Offer the patient advice on how to drive safely.
E)Listen attentively while the patient talks about her fears.

Question 71

__________ data include the patient's blood pressure, TPR, and weight.

Question 72

Lois Anderson was recently diagnosed with a functional disorder of the colon.Which of the following is true about her condition?

A)Her laboratory results are negative.
B)A colonoscopy reveals abnormal tissue.
C)Clinical signs indicate disease.
D)None of the above are true.

Question 73

__________ care recognizes that a patient's health is affected by multiple factors, not just physical ones.

Question 74

Which of the following is most important when conducting a patient interview?

A)Calling the patient by his or her first name
B)Sharing stories about the neighborhood
C)Providing uninterrupted privacy
D)Documenting every word the patient uses to describe the health problem

Question 75

Which of the following explains a sign of disease?

A)Patient c/o pain
B)Reports of dizziness for 3 days
C)Abdominal cramping for 2 weeks
D)Elevated blood pressure

Question 76

Therapeutic interactions with children include all of the following except:

A)allowing the child to decide whether a breathing treatment is needed
B)permitting the child to play with your stethoscope
C)praising the child for cooperative behavior
D)playing a game to distract the child

Question 77

The physician's initial impression of the patient's presenting problem is called the __________.

Question 78

Mrs.Elizabeth Stewart was recently diagnosed with diabetes mellitus type 2.She refuses to meet with a dietician because, she states, "The tests must be wrong.No one in my family has diabetes." Which defense mechanism is she displaying?

A)Sublimation
B)Denial
C)Repression
D)Suppression

Question 79

Which of the following is not true of holistic patient care?

A)The focus of care is the patient's disease process.
B)The physician considers the patient's ability to pay for treatment.
C)The patient's emotional state is investigated.
D)The medical assistant investigates lifestyle factors that may contribute to disease.

Question 80

The medical assistant must consistently request __________ from the patient to determine the patient's understanding of the message.