The position on a clock, topographic notations, and anatomic landmarks:
Response Descriptions of the locations of findings are universally referenced by using
Feedback: positions on a clock, topographic notations, or anatomic landmarks.
Question 2
During a history-taking session, Mr. B. appears to be avoiding certain questions. He keeps
looking out the window. What should the caregiver do?
Response When the patient dissembles, do not push too hard for an answer. Allow the
Feedback: interview to go on and come back to it later. Learning all that you may need
to know about a patient may not happen in one interview.
Question 3
,Ms. T. is crying and states that her mother couldn t possibly have a tumor. No one else in the
family, exclaims the daughter, has ever had cancer! The most appropriate response to Ms. T.
would be:
Response This is the only answer that is a direct exploration of the daughter s concern.
Feedback: The health care provider can explain and clarify the concerns of the
daughter.
Question 4
Subjective and symptomatic data are:
Response Subjective data, as well as symptomatic data, should not be part of the
Feedback: physical examination findings; rather, their documentation is appropriate for
the history portion.
Question 5
A 36-year-old woman complains that she has had crushing chest pain for the past 2 days. She
seems nervous as she speaks to you. An appropriate response is to:
Response With an anxious, vulnerable patient, it is best to not hurry; a calm
,Feedback: demeanor will communicate caring to the patient.
Question 6
Mr. F. is speaking with you, the health care provider, about his respiratory problem. Mr. F.
says, I ve had this cough for 3 days, and it s getting worse. You reply, Tell me more about
your cough. Mr. F. states, I wish I could tell you more. That s why I m here. You tell me what
s wrong! Which caregiver response would be most appropriate for enhancing communication?
Response This is the only response aimed at focusing on the chief compliant, to
Feedback: gather more data and does not digress from the issue.
Question 7
Periods of silence during the interview can serve important purposes, such as:
Response Silence is a useful tool during interviews for the purpose of reflection,
Feedback: summoning of courage, and displaying compassion. It is usually a clue for
you to go slower and not to push too hard.
Question 8
Which part of the information contained in the patient s record may be used in court?
, Response Anything that is entered into a patient s record, in paper or electronic form,
Feedback: is a legal document and can be used in court.
Question 9
Which of the following formats would be used for visits that address problems not yet identified in
the problem-oriented medical record (POMR)?
Follow-
up visits for problems identified in the POMR are recorded in the progress notes. Those visits not i
dentified as problems are recorded using the SOAP format. Careful review of all SOAP notes on a
regular basis will detect the emergence of a condition that explains the patient scomplaints; at that
point, SOAP documentation is stopped.
Question 10
Mary Jane has brought in her 16-year-old son, Kyle. She states that he has been sleeping
more, doesn t hang around his friends, and recently his girlfriend broke up with him. Your
most immediate question is to ask Kyle:
Response If you sense that a patient is contemplating suicide, you should ask about
Feedback: suicidal ideation directly.
Question 11
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