MA: Medical Records & Vital Signs Review

Conclusions drawn from an interpretation of data are known as:

Medical impressions

What is the chief complaint?

The symptom causing the patient the most trouble

How far should the probe be inserted when measuring the rectal temperature of an infant?

a. 1/2 inch

If a patient's blood pressure is 130/85 mm Hg, the patient's pulse pressure would be:

a. 45

What is the normal range for the resting pulse rate of an adult?

a. 60 to 100 beats/min

The oxygen saturation level of a healthy individual is:

a. 95% to 99%

The rectal site should NOT be used to take the temperature of:

a. A newborn

What is an objective symptom?

a. A symptom that can be observed by another person

Which of the following individuals may normally exhibit bradycardia?

a. A trained athlete

How does a temporal artery temperature reading compare with and oral body temperature reading?

a. Approximately 1 degree higher than oral reading

You are taking the pulse and find it feels extremely strong and full. How would you record this?

a. Bounding

What is the term used to describe the process of making written entries about a patient in the medical record?

a. Charting

Which of the following symptoms are experienced by a patient when his or her temperature begins to rise?

a. Coldness and chills

The transfer of heat from one object to another is known as:

a. Conduction

What is the term used to describe a bluish discoloration of the skin caused by a lack of oxygen?

a. Cyanosis

The patient registration record consists of:

a. Demographic and billing information

The phase in the cardiac cycle in which the heart relaxes between contractions is known as:

a. Diastole

You take Mrs. Main's temperature at 7:00 A.M.; it reads 97.8F. At 3:00 P.M., you take her temperature again; it reads 99F. How might you account for the indifference?

a. During sleep, body metabolism slows down

A review of the health status of blood relatives is known as:

a. Family history

How does physical exercise affect the pulse?

a. Increases the pulse rate

Reasons why the temporal artery is a good site for measuring body temperature included all of the following EXCEPT:

a. It is not affected by ambient temperature

The social history is important because the following may have an impact on the patient's condition:

a. Lifestyle

A diaphragm chestpiece on a stethoscope is most useful for hearing:

a. Lung and bowel sounds

The control center for involuntary respiration is the:

a. Medulla

A temperature of 97.6F is classified as:

a. Normal

Where is the radial pulse located?

a. On the thumb side of the wrist

What is the term used to determine breathing that is easier in a sitting position?

a. Orthopnea

A tympanic membrane thermometer should not be used to measure temperature on a patient who has:

a. Otitis externa

Which of the following pulse sites can be used to assess circulation to the foot?

a. Posterior tibial

The systolic blood pressure represents the:

a. Pressure in the arteries when the ventricles contract

What effect could patient movement have on the pulse oximetry procedure?

a. Prevents the probe from picking up pulse signal

Black ink should be used when recording in the patient's chart to:

a. Provide a permanent record

The acronym for the format used o organize POR progress notes is:

a. SOAP

Which of the following conditions is often characterized by hypopnea?

a. Sleep disorders

Data obtained from the patient is recorded in POR progress notes under:

a. Subjective data

Laboratory tests ordered on a patient at an outside laboratory should be charted to provide documentation in case the following occurs:

a. The patient does not undergo the test

What is the past medical history?

a. The patient's previous disease, injuries, and operations

Before taking body temperature with an electronic thermometer:

a. The probe must be covered with a disposable cover

After measurement of rectal temperature with an electronic thermometer, the probe cover should be ejected into:

a. The regular trash

When measuring blood pressure, the first clear tapping sound represents:

a. The systolic pressure

The function of hemoglobin is to:

a. Transport oxygen in the body

All of the following are examples of diagnostic reports EXCEPT:

a. Urinalysis report

When a medical assistant witnesses a patient's signature, it means that he or she:

a. Verified the patient's identity and watched the patient sign the form

Which of the following situations requires the completion of a release of medical information form?

a. When a patient transfers records to a new physician

Which of the following individuals has the fastest pulse rate?

a. infant

What is the normal range of body temperature?

b. 97F to 99F

If a rectal temperature of 99F was taken orally, it would register as:

b. 98F

Which of the following individuals would be LEAST likely to have dyspnea?

b. A patient with arthritis

All of the following are included in the patient registration record EXCEPT:

b. Allergies

What is a symptom?

b. Any change in the body or its functioning that indicates disease

When measuring blood pressure, the patient's arm should be positioned:

b. At hear level

Over which artery is the stethoscope placed when taking the blood pressure?

b. Brachial

Which of the following pulse sites is often used to monitor pulse during exercise?

b. Carotid

The purpose of the power-on self-test (POST) performed by a pulse oximeter is to:

b. Check the internal systems of oximeter

Which of the following does NOT affect the SpO2 reading?

b. Dark pigmented skin

What is the form used to describe excessive perspiration?

b. Diaphoresis

What is the term used to describe the point of lesser pressure on the arterial walls when assessing blood pressure?

b. Diastolic pressure

Which of the following is the abbreviation for a medical record stored on the computer?

b. EMR

Which of the following terms refers to a fever?

b. Febrile

What is the term used to describe an abnormal decrease in the rate and depth of respiration?

b. Hypopnea

What is the name given to the heat regulating center of the body?

b. Hypothalamus

What term designates a decrease in the oxygen saturation of the blood?

b. Hypoxemia

The purpose of the tab on a file folder is to:

b. Identify the contents of the folder

The apical pulse is located:

b. In the fifth intercostal space at the junction of the left midclavicular line

All of the following must be done when charting EXCEPT:

b. Include the patient's name at the beginning of each entry

Normal blood pressure for an adult is:

b. Less than 120/80

A vague sense of body discomfort, weakness, and fatigue that often marks the onset of a disease is known as:

b. Malaise

Which of the following is an example of a subjective symptom?

b. Pain

Which of the following reports consists of a macroscopic and microscopic description of tissue removed during surgery?

b. Pathology report

An expansion of the chief complaint is known as the:

b. Present illness

The purpose of HIPAA is to:

b. Provide patients with more control over the use and disclosure of their health information

A temperature of 103F is classified as:

b. Pyrexia

Which of the following probes should be selected to measure rectal body temperature with an electronic thermometer?

b. Red-collared

What is the name given to the type of fever in which a wide range of temperature fluctuations occur, all of which are above normal?

b. Remittent

A consent to treatment form is required for:

b. Sebaceous cyst removal

Which of the following indicates that the proper cuff size has been selected?

b. The bladder of the cuff encircles 80% of the circumference of the arm

Which of the following may occur if the lens of a tympanic membrane thermometer is dirty?

b. The reading may be falsely low

You are measuring the pulse and find it feels weak and rapid. How would you record this?

b. Thready

The purpose of measuring pulse includes all of the following EXCEPT:

b. To determine if the patient is developing hypertension

Why is it important to document any instructions provided to the patient?

b. To protect the physician legally if the patient is harmed by not the following the instructions

The purpose of progress notes is to:

b. Update the medical record with new patient information

What is the term used to describe dizziness?

b. Veritgo

The axilla is recommended as the preferred site for taking the temperature of:

b. a preschooler

Which of the following is a correct example for recording the chief complaint?

c. "Burning in the chest and coughing for the past 2 days."

The normal respiratory rate of an adult ranges from:

c. 12 to 20 respirations per minute

Which of the following represents the average normal body temperature?

c. 98.6F

What is ROS?

c. A systematic review of each body system

The lens of a tympanic membrane thermometer should be cleaned with:

c. An antiseptic wipe

What is the term used to describe temporary cessation of breathing?

c. Apnea

The physician's interpretation of the patient's condition is recorded in POR progress notes under:

c. Assessment

A procedure should be charted immediately after being performed to:

c. Avoid forgetting certain aspects of the procedure

The health history is taken:

c. Before the physician performs the physical examination

What type of cuff would probably be needed to measure blood pressure on an underweight adult weighing 93 lbs?

c. Child

A narrative report of an opinion about a patient's condition by a practitioner other than the attending physician is known as a:

c. Consultation report

Which of the following prevents ambient light from interfering with the SpO2 reading?

c. Covering the probe with a washcloth

Why should a recording in the medical record never be erased or obliterated?

c. Credibility is reduced if the physician is involved in litigation

Which of the following is the correct way to sign a charting entry?

c. D. Bennett, CMA

Which of the following is an example of familial disease?

c. Diabetes mellitus

Which of the following tests might be ordered for a patient with a dysrhythmia?

c. ECG

Internal respiration is the:

c. Exchange of oxygen and carbon dioxide between the blood and body cells

All of the following can be used as a probe placement site EXCEPT the:

c. Finger of an arm to which an automatic blood pressure cuff is applied

Which of the following provides subjective data about a patient to assist the physician in arriving at a diagnosis?

c. Health history

What type of breathing may occur with a panic attack?

c. Hyperventilation

Excessive pressure should not be applied when measuring pulse because:

c. It could close off the radial pulse

In a source-oriented record, a radiology report would be filed under which of the following chart dividers?

c. Lab/X-ray

A report of the analysis of body specimens is known as a:

c. Laboratory report

For an artery to be considered as a pulse site, it must be:

c. Located over a firm tissue such as bone

One respiration consists of:

c. One inhalation and one exhalation

A copy of the patient's emergency department report is sent to the:

c. Patient's family physician

Which of the following helps a patient with a disability learn new skills to perform the activities of daily living?

c. Physical therapy

With reverse chronological order, the most recent document is:

c. Placed in front of the other documents

All of the following are included in an operative report EXCEPT:

c. Prognosis

Which of the following is used to describe the condition in which the radial pulse rate is less than the apical pulse?

c. Pulse deficit

Which of the following could result in an inaccurate temporal artery temperature reading?

c. Quickly scanning the forehead

You are measuring the pulse and find it has a normal rhythm and volume. How should you record this?

c. Regular and strong

All of the following are risk factors for developing hypertension EXCEPT:

c. Sleep apnea

Which of the following terms describes an abnormally fast pulse rate?

c. Tachycardia

Pulse oximetry provides the physician with information on:

c. The amount of oxygen being delivered to the tissues

Blood pressure measures:

c. The force exerted on the walls of the arteries by the blood

Most of the heat produced in the body is through:

c. Voluntary muscle contractions

Where is the femoral pulse located?

c. in the middle of the groin

If an axillary temperature of 100F was taken orally, it would register as:

d. 101F

Which of the following BP readings would be classified as hypertension, stage 1?

d. 144/92 mm Hg

If a patient's pulse rate is 80 beats/min, the patient's respirations would most likely be:

d. 20 respirations per minute

Chemical thermometers must be stored in:

d. A cool area

Which of the following individuals has the slowest respiratory rate?

d. Adult

If the patient's fingers are cold when performing pulse oximetry, the medical assistant should:

d. Ask the patient to rub his or her fingers together

All of the following are examples of physical therapy EXCEPT:

d. Breathing treatments

All of the following assist int eh collection of data for a health history EXCEPT:

d. Calling the patient "honey"

During exhalation:

d. Carbon dioxide is removed from the lungs

All of the following are included in the social history EXCEPT:

d. Chronic illnesses

Proper care of pulse oximeter includes:

d. Cleaning the monitor with a nonabrasive cleaner

All of the following tend to increase body temperature EXCEPT:

d. Cold weather

What is the name given to the type of fever in which the temperature fluctuates minimally, but always remains elevated?

d. Continuous

Which of the following reports consists of an account of the significant events of a patient's hospitalization?

d. Discharge summary report

A decrease in the amount of water in the body is known as:

d. Dyhydration

What is the term used to describe and irregularity in the heart's rhythm?

d. Dysrthythmia

All of the following may cause a decrease in the SpO2 reading EXCEPT:

d. Gastritis

Where is the popliteal pulse located?

d. In the back of the knee

What term is used to describe a patient who has been admitted to the hospital for a least one overnight stay?

d. Inpatient

A rectal thermometer must be lubricated before insertion to prevent:

d. Irritation of the rectal mucosa

A yellow color to the skin that is fist observed in the whites of the eyes in termed:

d. Jaundice

A temperature of 100F is classified as:

d. Low-grade fever

Blood pressure is measured in:

d. Millimeters of mercury

Which of the following would NOT be included on a medication record for medication administered at the office?

d. Number of refills

When measuring blood pressure, the Korotkoff phase in which the sounds disappear is?

d. Phase V

All of the following are included in the database section of a POR EXCEPT:

d. Plan of treatment

When taking axillary body temperature, the arm should be held close to the body to:

d. Prevent air currents from affecting the reading

Which of the following represents an ERROR in blood pressure technique?

d. Releasing the air in the cuff as slowly as possible

The abbreviation used to record oxygen saturation as measured by a pulse oximeter is:

d. SpO2

When the patient's forehead is sweating, which of the following ensures an accurate temporal artery temperature reading?

d. Taking the temperature behind the earlobe

Which of the following is NOT a function of the medical record?

d. To share information between members of the patient's family

Which of the following questions should be used to elicit the chief complaint from a patient?

d. What seems to be the problem?

Which of the following must be included in informed consent?

e. All of the above (An explanation of risks involved with the procedure, Any alternative treatments or procedures available, The prognosis & The purpose of the recommended procedure)

Which of the following are symptoms that may occur during the course of a fever?

e. All of the above (Headache, Increased pulse and respirations, Increased thirst and Loss of appetite

What information is contained in the medical record?

e. All of the above (Health history, Results of the physical examination, Laboratory reports and Progress notes)

Which of the following services may be provided through home health care?

e. All of the above (IV therapy, Respiratory care, Rehabilitation & Maternal-child care)

The temporal artery site can be used to measure body temperature in:

e. All of the above (Infants, Children, Adults & Elderly)

Which of the following has an effect on blood pressure?

e. All of the above (Pain, Bladder distention, Body position & Smoking)

All of the following are included on a release of medical information from EXCEPT:

e. Medications being taken by the patient

All of the following are included in the past medical history EXCEPT:

e. Occupation

Flushed skin usually indicates:

An elevated temperature