chapter 21 and 25

Information that you gather from a patient interview is considered A) subjective. B) objective. C) assessment. D) evaluation.

A) subjective.

Which of the following involves repeating or paraphrasing the patient's comments? A) Restatement B) Clarification C) Reflection

A) Restatement

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.

A) review of systems.

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?"

B) "Does your head hurt?"

What is the best way to obtain specific information about a patient when taking the medical history? A) Summarize the facts reveled 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

B) Ask direct questions that can be answered briefly

Which of the following involves asking a question or summarizing a patient's thoughts? A) Restatement B) Clarification C) Reflection

B) Clarification

Which of the following includes childhood diseases? A) Family history B) Past history C) Social history D) Database E) ROS

B) Past history

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

B) Problem Oriented

What does it mean when medical assistant 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) The privacy of the area in which the interview takes place D) The efficiency of the medical assistant in conducting the interview

B) They are able to hear what patients say without judging the content

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.

B) provides feedback to clarify the patient's message.

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?"

C) "What brings you to the office today?"

Objective data include which of the following? A) Complaints of pain B) Social history C) Blood pressure recordings D) Past medical history

C) Blood pressure recordings

Which of the following involves stating an observation or recognition of a patient's feeling? A) Restatement B) Clarification C) Reflection

C) Reflection

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

C) Social history

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 assistants 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

C) The privacy of the area in which the interview takes place

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 relationship with them D) You are polite and punctual

C) You have smooth, pleasant relationship with them

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 open-ended questions about the headaches

D) Ask the patient open-ended questions about the headaches

Which of the following includes demographic information? A) Family History B) Past History C) Social History D) Database E) ROS

D) Database

Which of the following includes insurance information? A) Family History B) Past History C) Social History D) Database E) ROS

D) Database

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

D) Symptom

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) System Review

D) System Review

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

E) ROS

What type of breath odor may be observed in patients with diabetes? a. Acetone or fruity b. Musty c. Tangy or citrus d. Ammonia

a. Acetone or fruity

Which of the following speech defects is the inability to speak because of loss of the voice, commonly seen with laryngitis or overuse of the voice? a. Aphonia b. Sensory aphasia c. Dysphasia d. Motor aphasia

a. Aphonia

During patient assessment, which of the following is an example of a subjective finding? a. Difficulty breathing b. Temperature c. Blood pressure and pulse d. Palpable mass

a. Difficulty breathing

Which type of tissues is packed closely together with little or no intercellular material, and is classified according to shape? a. Epithelial tissue b. Connective tissue c. Muscle tissue d. Nervous tissue

a. Epithelial tissue

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 is true.

a. Her laboratory results are negative.

Which of the following is the medical assistant's responsibility when preparing the patient for a physical examination? a. Make sure all informed consent forms have been signed. b. Write prescriptions for patients in need of refills. c. Check the patient's eye with an ophthalmoscope. d. Perform a fecal occult blood test.

a. Make sure all informed consent forms have been signed.

A percussion hammer is used for which part of the physical examination? a. Neurologic b. Gastrointestinal c. Urinary d. Respiratory

a. Neurologic

What is used to examine the interior of the eye, including the retina and intraocular vessels? a. Ophthalmoscope b. Otoscope c. Palpation d. Stethoscope

a. Ophthalmoscope

If you are interested in working with patients of all ages who seek help for a wide variety of disorders, employment with which medical specialist would be your best choice? a. Primary care physician b. Oncologist c. Internist d. Physical medicine physician

a. Primary care physician

Which of the following is a stage 3 requirement for Medicare and Medicaid EHR Incentive Program? a. Providers are expected to show improved patient outcomes. b. Maintain current patient medication list. c. Include lab test results in patient's EHR. d. Provide summary of care for patients transferring to another provider.

a. Providers are expected to show improved patient outcomes.

Which of the following positions is sometimes referred to as the "lateral position" and used for rectal examinations? a. Sims' position b. Lithotomy position c. Prone position d. Trendelenburg's position

a. Sims' position

Which position requires the patient to lie flat on his or her back? a. Supine b. Prone c. Sims' d. Fowler's

a. Supine

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

a. Suppression

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.

a. The focus of care is the patient's disease process.

Plantar reflexes are tested with which of the following? a. The patient in an upright or a supine position b. With either the fingers or the reflex hammer c. Using tapotement d. None of the above

a. The patient in an upright or a supine position

Which of the following is a good example of an open-ended question? a. What brings you to the doctor today? b. Do you have a headache? c. What is your date of birth? d. Have you ever broken a bone?

a. What brings you to the doctor today?

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.

a. allowing the child to decide whether a breathing treatment is needed.

The usual sequence of the general physical examination moves from the a. head toward the feet. b. center of the body. c. area where there is a complaint. d. trunk outward to the limbs.

a. head toward the feet.

The physician uses a(n) ______ to examine the eyes. a. ophthalmoscope b. otoscope c. flashlight d. ophthalmoscope

a. ophthalmoscope

Sally Tipoke, age 17, is scheduled for her first Pap test 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."

b. "You look worried about the exam. Can I answer any questions?"

How does the physician typically begin the examination of body parts and systems? a. By assessing the body part causing the patient's complaint b. By starting with the head and working methodically toward the feet c. By auscultating breath and heart sounds d. By performing a breast examination on female patients

b. By starting with the head and working methodically toward the feet

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

b. Denial

As a result of his CVA, Mr. Johnson suffers from motor aphasia. What does this mean? a. He pronounces words easily but identifies items inaccurately. b. He knows what he wants to say but cannot pronounce the words clearly. c. He is unable to talk or write because of the damage to his brain. d. He is able to talk clearly if given enough time.

b. He knows what he wants to say but cannot pronounce the words clearly.

Clubbing of the fingertips is associated with which of the following health problems? a. Skin conditions b. Heart or lung disease c. Congenital deformity d. Inherited defect

b. Heart or lung disease

Which examination position is used for rectal or sigmoid examinations? a. Dorsal recumbent b. Knee-chest c. Lithotomy d. Trendelenburg's

b. Knee-chest

Which term is associated with the process of measuring? a. Auscultation b. Mensuration c. Manipulation d. Palpation

b. Mensuration

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

b. Neurologic

Which of the following are learned behaviors that are greatly influenced by our family and cultural backgrounds? a. Active listening b. Nonverbal communication c. Verbal messages d. None of the above

b. Nonverbal communication

Which of the following examination positions can be used for a rectal examination? a. Trendelenburg's b. Sims' c. Supine d. Prone

b. Sims'

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.

b. hypertension and leg cramps.

The examination method used to assess the patient's manner of walking is a. palpation. b. inspection. c. manipulation. d. ROM.

b. inspection.

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?"

c. "Tell me about how your arm feels right now."

When writing progress (SOAP) notes, in which section would the provider's preliminary diagnosis of the cause of the patient's chief complaint be placed? a. S b. O c. A d. P

c. A

Which of the following processes involved in active listening seeks to summarize or simplify the sender's thoughts and feelings or to resolve any confusion in the message? a. Restatement b. Reflection c. Clarification d. Feedback

c. Clarification

Which of the following positions may be used when an anterior examination is to be done, but the patient has back pain? a. Lithotomy b. Semi-Fowler's c. Dorsal recumbent d. Horizontal recumbent

c. Dorsal recumbent

Which of the following positions is achieved by lying prone with the head down, the knees bent, and the buttocks elevated? a. Dorsal recumbent b. Lithotomy c. Knee-chest d. Sims' e. Trendelenburg's

c. Knee-chest

Which examination position is used for gynecologic examinations? a. Dorsal recumbent b. Knee-chest c. Lithotomy d. Trendelenburg's

c. Lithotomy

Which method of examination is considered separate from the four standard methods? a. Inspection b. Auscultation c. Manipulation d. Percussion

c. Manipulation

Which of the following best describes a practitioner who has earned advanced degrees and licensure and who can work in primary or specialty medical practices and clinics? a. Family practitioner b. Internist c. Nurse practitioner d. Obstetrician

c. Nurse practitioner

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

c. Providing uninterrupted privacy

Which is the best method of moving a heavy object? a. Pull it in the direction it needs to be moved. b. Twist toward the object and slide it toward you. c. Roll or push the item in the desired direction. d. Bend at the waist and use arm muscles to push the object.

c. Roll or push the item in the desired direction.

Which type of data collection is NOT associated with holistic care? a. Physical b. Cognitive c. Social d. Behavioral

c. Social

One of the medical assistant's responsibilities when preparing a room for a patient's physical examination is to gather the instruments and supplies needed. Which of the following is not needed for a routine physical examination? a. Specimen bottles b. Fecal occult blood test supplies c. Sterile gloves d. Lubricating gel

c. Sterile gloves

Which of the following positions is used for examination of the front of the body, including the heart, breasts, and abdominal organs? a. Fowler's position b. Dorsal recumbent position c. Supine (horizontal recumbent) position d. Lithotomy position

c. Supine (horizontal recumbent) position

A few months ago, Mr. Thomas Johnson suffered a stroke that left him with weakness on the right side. You need to assist him from his wheelchair onto the examination table. Which technique should you use? a. Support Mr. Johnson on his right side. b. Bend at the waist and support Mr. Johnson as he stands. c. Support Mr. Johnson close to your body on his left side. d. You do not have to worry about locking the chair wheels, because you are providing support.

c. Support Mr. Johnson close to your body on his left side.

When lifting a heavy object, the medical assistant should a. bend at the waist, keeping the back straight. b. pull the object in the direction needed. c. keep the weight as close as possible to the body. d. twist and reach for the object.

c. keep the weight as close as possible to the body.

When preparing a patient for a physical examination, the medical assistant is responsible for all of the following except a. providing the patient with a gown and instructions on how to wear it. b. making sure the patient has emptied the bladder. c. providing refill prescriptions as needed. d. measuring and recording vital signs.

c. providing refill prescriptions as needed.

The physician performs manipulation during the physical examination to gain information about the a. condition of internal organs. b. irregularities that can be felt just beneath the skin. c. range of motion of a joint. d. strength of the muscles.

c. range of motion of a joint.

An instrument used to test auditory acuity is the a. ophthalmoscope. b. otoscope. c. tuning fork. d. Snellen

c. tuning fork

The physician might use a __________ to assess a patient's ability to detect sound vibrations. a. Snellen chart b. tongue blade c. tuning fork d. reflex hammer

c. tuning fork

The sclera of the eye is described as the a. tissue that lines the interior part of the eye. b. part of the eye that is responsible for eye color. c. white part of the eye that may show inflammation. d. area of the eye where tears form.

c. white part of the eye that may show inflammation.

Which of the following is a patient confidentiality practice supported by HIPAA regulations? a. The initial patient information is gathered in the office waiting room. b. The patient's record is placed on the examination room door with the name facing out so it can be easily identified by the physician. c. Diagnostic tests for one patient are scheduled while another patient is standing by, waiting for discharge. d. A sign-in sheet is used that covers the names of patients who had signed in previously.

d. A sign-in sheet is used that covers the names of patients who had signed in previously.

Which of the following is considered a safeguard mandated by HIPAA? a. Passwords access to all electronic health records b. Computer monitor shields c. Turning monitors away from patient traffic areas d. All of the above

d. All of the above

During a physical examination, the physician discovers a bruit. What method would she be using to make this discovery? a. Manipulation b. Palpation c. Percussion d. Auscultation

d. Auscultation

Which of the following fingernail conditions may indicate local infection or systemic disease? a. Spooning of the main b. Beau's lines c. Clubbing fingertips d. Brittle, grooved, or lined nails

d. Brittle, grooved, or lined nails

Which body cavity protects organs of the nervous system? a. Thoracic cavity b. Pericardial cavity c. Ventral cavity d. Dorsal cavity

d. Dorsal cavity

When writing in a paper record and an error is made, which of the following document guidelines is acceptable? a. Scribble out error. b. Use whiteout to cover up the error. c. Erase the error. d. Draw a line through the error.

d. Draw a line through the error.

An otorhinolaryngologist is a physician who specializes in what area? a. Ear and throat b. Eye, ear, and throat c. Eye, ear, and nose d. Ear, nose, and throat

d. Ear, nose, and throat

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

d. Elevated blood pressure

What is the normal color of the tympanic membrane? a. Pink b. Slightly yellow c. Off-white d. Pearly gray

d. Pearly gray

What is the quickest and easiest method for checking skin turgor? a. Draw blood for analysis. b. Examine the patient's eyes. c. Examine the condition of the nails. d. Pinch the skin on the posterior surface of the hand.

d. Pinch the skin on the posterior surface of the hand.

Which examination position requires the medical assistant to raise the head of the bed to a 30- to 45-degree angle? a. Dorsal recumbent b. Fowler's c. Lithotomy d. Semi-Fowler's

d. Semi-Fowler's

Which of the following components of the medical history provide a guide to the patient's general health? a. Chief complaint b. Family history c. Social history d. Systems review

d. Systems review

Which examination position is used in emergencies for patients with severe hypotension or who are in shock? a. Dorsal recumbent b. Knee-chest c. Lithotomy d. Trendelenburg's

d. Trendelenburg's

The examination technique by which the practitioner listens to internal body signs is a. percussion. b. manipulation. c. palpation. d. auscultation.

d. auscultation.

The physician asks the medical assistant to position a patient on the examination table so that the patient can breathe more easily. The most appropriate position is a. dorsal recumbent. b. jackknife. c. lithotomy. d. semi-Fowler's. e. Trendelenburg's.

d. semi-Fowler's.

Which of the following positions is most appropriate for a patient having a breast examination? a. Dorsal recumbent b. Jackknife c. Lithotomy d. Semi-Fowler's e. Horizontal recumbent

e. Horizontal recumbent

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.

e. Listen attentively while the patient talks about her fears.