Complete Test Bank Ch.36 Wyma Patient Interview And History

Student name:__________

1) A subjective statement made by a patient describing the patient's most significant symptoms or signs of illness is the patient's __________.

2) Effective __________ means hearing what the patient says, thinking about it, and responding appropriately.

3) The patient's facial expressions and body language are examples of __________ communication.

4) You must have a broad __________ base to be able to ask questions that will elicit the most meaningful information about the patient.

5) At the end of an interview, you should __________ the information the patient provided and repeat it back to him for verification.

6) Patient interviews should be conducted in __________ and without interruptions.

7) Only the licensed practitioner can make a(n) __________, based on the patient’s symptoms and complaints.

8) The method of collecting patient data that requires more than a yes-or-no answer is asking __________ questions.

9) The method of collecting data that allows you to determine the patient's knowledge of the situation is asking __________ questions.

10) Restating as exactly as possible what the patient said is an example of __________ the patient’s responses.

11) Stating what you believe the patient is suggesting by his response is a technique known as __________.

12) The use of __________ by continuing to ask questions after the patient appears to have finished giving information is an ineffective means of data collection because the patient may feel you are invading her privacy.

13) "White coat syndrome" is a type of __________ related to seeing a medical provider.

14) When the patient shows signs of __________, every effort should be made to help the patient relax and release or reduce these feelings.

15) Classic symptoms of __________ are profound sadness and fatigue.

16) Signs of substance abuse or __________ can be mistaken for depression.

17) Taking larger-than-prescribed doses of a medication is an example of __________.

18) A physical or psychological dependence on a substance is called a(n) __________.

19) An unlikely explanation for an injury may be a sign of __________.

20) If you suspect a patient has been abused, you must report it to your supervisor or the __________.

21) Most patient charts are arranged with the entries in reverse __________ order.

22) The thoughts, feelings, and perception of a patient are __________ data when you document using the SOAP format.

23) Data that is readily apparent and measurable is __________ data.

24) The practitioner's diagnosis or impression of the patient's problem is documented in the __________ section of the SOAP format chart notes.

25) The practitioner decides that the patient needs blood and urine tests. The practitioner will document this in the medical record under the __________ of action section in the SOAP format.

26) Information is arranged according to who provided the information in __________ or source-oriented medical records.

27) Conditions or problems are identified by a number throughout the record until the problem is resolved in __________ medical records.

28) When an office uses __________ medical records, the records are accessible at any time and combine SOMR and POMR methods.

29) The Joint Commission (TJC) issued a "Do Not Use" list of __________, acronyms, and symbols that should not be used in an effort to reduce medical errors.

30) The __________ interview technique will help you remember the types of questions that are appropriate for the patient's condition.

31) Many offices use a variation of the __________ note to document routine follow-ups of established patients with ongoing conditions such as hypertension or arthritis.

32) The patient's name, Social Security number, and birth date are documented in the __________ data section of the health history form.

33) The __________ is the reason the patient came to visit the practitioner. It should be short and specific and should cover subjective and/or objective data.

34) The history of __________ illness includes detailed information about the chief complaint, including when the problem started and what the patient has done to treat the problem.

35) The __________ medical history includes important information about medications and allergies.

36) The use of alcohol, tobacco, recreational drugs, or other chemical substances is documented in the __________ history.

37) The Joint Commission (TJC) and the __________ (ISMP) are two organizations whose mission includes promotion of patient safety by publishing an official “Do Not Use” list of abbreviations in an effort to reduce medical errors.

38) When using the PQRST interview technique, the S stands for __________.

39) Which of the following is charted as subjective data?

A) test results
B) practitioner’s examination
C) patient's chief complaint
D) vital signs
E) plan of action

40) The practitioner’s diagnosis or impression of the patient’s condition is the __________.

A) subjective data
B) assessment
C) objective data
D) plan of action
E) problem list

41) Which of the following information would be documented under the plan of action?

A) medications prescribed and tests to be done
B) practitioner’s diagnosis
C) patient's chief complaint
D) results of the practitioner’s examination
E) patient's vital signs

42) Which of the following is appropriate for conducting a successful interview?

A) Tell the patient that you "need to take a history."
B) Avoid the use of icebreakers.
C) Give the patient your opinion about a diagnosis.
D) Ask leading questions so the patient knows the right answer.
E) Assist the patient to a private room and close the door.

43) Which of the following methods of collecting patient data requires more than a yes-or-no answer and encourages the patient to explain the situation?

A) asking leading questions
B) challenging a patient
C) asking open-ended questions
D) focusing on the patient
E) probing

44) Methods of collecting patient data include mirroring, which includes __________.

A) blocking further communication
B) restating what the patient says almost exactly as the patient says it
C) interpreting what you believe the patient is saying
D) motivating the patient to describe the situation in his own way
E) asking closed-ended questions

45) "Where would you like to begin?" is an example of which method of collecting patient data?

A) challenging the patient
B) asking hypothetical questions
C) encouraging the patient to take the lead
D) asking open-ended questions
E) focusing on the patient

46) "You seem to be making progress, don't you agree?" is an example of which method of collecting patient data?

A) asking leading questions
B) probing
C) challenging the patient
D) asking open-ended questions
E) encouraging the patient to take the lead

47) Which of the following offers the patient little freedom to explain his answers and requires only yes-or-no answers?

A) probing
B) agreeing or disagreeing with the patient
C) asking leading questions
D) asking closed-ended questions
E) mirroring the patient's responses

48) Which of the following is characteristic of depression?

A) It occurs most commonly in children.
B) The signs of depression are the same as the signs of substance abuse or addiction.
C) Symptoms include difficulty falling asleep, loss of appetite, and loss of energy.
D) Depression is always easy to diagnose.
E) Depression seems to occur most frequently between ages 20 and 30.

49) Which of the following commonly abused drugs are amphetamines/stimulants?

A) Phenobarbital and amobarbital
B) Valium, Ativan, and Librium
C) Dexedrine, Benzedrine, and methamphetamine
D) Butisol and secobarbital
E) Anadrol and Depo-testosterone

50) Which of the following are common effects of LSD?

A) slowed thinking, slowed reflexes, slowed respiration, loss of anxiety
B) grandiose feelings, hallucinations, mystical experiences, flashbacks
C) decreased level of consciousness, detachment, drowsiness, impaired judgment
D) altered mental status, confusion, paranoia
E) hyperactivity followed by exhaustion, insomnia, loss of appetite

51) Which of the following are other names for cocaine?

A) snow, crack
B) acid, microdot
C) pot, grass, reefer
D) angel dust, rocket fuel
E) monkey, white stuff

52) Angel dust is also known as __________.

A) LSD
B) cocaine
C) PCP
D) opium
E) heroin

53) The information in the patient's chart is __________.

A) a reminder to the medical assistant of what has occurred in the past
B) primarily for the third-party payer's use
C) a mechanism to provide information to the patient about treatments
D) a legal record of treatment rendered
E) a tool for diagnosing illness

54) During a patient interview, you note signs of anxiety in the patient. You may be able to help the patient by __________.

A) stopping the interview
B) letting him take the lead
C) bringing in the practitioner
D) telling him to calm down
E) allowing him to describe his feelings

55) Which of these patient behaviors is a classic symptom of depression?

A) profound sadness
B) rapid speech
C) obsession with exercising
D) anxiety about entering the health-care system
E) sleeping soundly at night

56) The need for __________ in the medical record makes it essential that medical terminology and precise descriptions are used when charting.

A) conciseness
B) completeness
C) clarity
D) confidentiality
E) chronological order

57) Which of the following statements does not apply to the Patient's Bill of Rights (Patient Care Partnership)?

A) Patients should know the long-term costs of treatment choices.
B) A privacy notice must be prominently posted within the hospital.
C) The identity of people involved in care should be known to patients.
D) Patients should be informed of available resources for resolving disputes.
E) Patients can choose a representative to make healthcare decisions.

58) Which of the following statements applies to HIPAA requirements?

A) Long-term costs of treatment choices must be explained to patients.
B) A privacy notice must be prominently posted within the hospital.
C) Patients should know the identity of people involved in care.
D) Patients should be informed of available resources for resolving disputes.
E) Reasonable continuity of care should be provided to patients.

59) Which of the following does not apply to HIPAA requirements?

A) Patient consent is required to disclose protected information.
B) Health-care facilities must provide patients with a written notice of their privacy practices.
C) The medical assistant should be informed of available resources for resolving disputes.
D) Health-care facilities must inform patients, in writing, about disclosure of identifiable health information.
E) The patient's written authorization is required for disclosures not permitted by a hospital's privacy notice.

60) Which of the following applies to HIPAA requirements?

A) Patients should know the long-term costs of treatment choices.
B) Patients should know the identity of people involved in care.
C) Patients should be informed of available resources for resolving disputes.
D) Healthcare facilities must inform patients, in writing, about disclosure of identifiable health information.
E) To the extent permitted by law, patients may refuse treatment.

61) Which of the following approaches allows you to determine the patient's knowledge of the situation and whether it is accurate?

A) agreeing with the patient
B) asking questions that require yes-or-no answers
C) asking hypothetical questions
D) probing for more information
E) challenging the patient

62) Which of the following is an ineffective means of collecting data?

A) asking open-ended questions
B) probing for more information
C) asking hypothetical questions
D) encouraging patient to take the lead
E) mirroring the patient's responses

63) Asking the patient "Can you tell me more about your symptoms?" is which method of collecting patient data?

A) asking closed-ended questions
B) asking open-ended questions
C) asking hypothetical questions
D) encouraging patient to take the lead
E) asking leading questions

64) The question "What would you do if you had chest pain?" represents which of the following methods of patient data collection?

A) asking closed-ended questions
B) asking open-ended questions
C) asking hypothetical questions
D) challenging the patient
E) asking leading questions

65) Which method of patient data collection does the statement "So let me see if I understand; The pain only occurs at night." represent?

A) asking closed-ended questions
B) verbalizing the implied
C) asking open-ended questions
D) focusing on the patient
E) challenging the patient

66) Maintaining eye contact is a characteristic of which of these methods of data collection?

A) asking closed-ended questions
B) verbalizing the implied
C) asking open-ended questions
D) focusing on the patient
E) probing

67) The question "Are you sure about that? It doesn't make sense to me." represents which method of collecting patient data?

A) asking closed-ended questions
B) focusing on the patient
C) challenging the patient
D) encouraging the patient to evaluate his situation
E) probing

68) Which method of data collection does the question "What do you think is going on with you?" represent?

A) asking open-ended questions
B) focusing on the patient
C) asking hypothetical questions
D) mirroring the patient's responses
E) encouraging the patient to evaluate his situation

69) When you assume an open and relaxed body posture, you are demonstrating which data collection method?

A) asking open-ended questions
B) focusing on the patient
C) asking hypothetical questions
D) encouraging the patient to evaluate his situation
E) agreeing with the patient

70) The question "Where would you like to begin?" represents which method of data collection?

A) asking open-ended questions
B) asking hypothetical questions
C) mirroring the patient's responses
D) encouraging the patient to evaluate his situation
E) encouraging the patient to take the lead

71) An increased heart rate, confusion, anxiety, and paranoia are effects of which of the following drugs?

A) depressants
B) ecstasy
C) anabolic steroids
D) inhalants
E) narcotics

72) A decreased heart rate and blood pressure, drowsiness, and poor concentration are effects of __________.

A) GHB
B) ecstasy
C) anabolic steroids
D) inhalants
E) amphetamines

73) Irene is a 26-year-old patient who is in the office for her annual physical examination. While you are interviewing her, she says she is feeling wonderful. She tells you she has been having mystical experiences and seems unusually aware of things around her. Which of the following drugs has she probably taken?

A) GHB
B) LSD
C) Heroin
D) Ativan
E) Benzedrine

74) Alternating euphoria and apprehension is an effect of __________.

A) depressants
B) anabolic steroids
C) inhalants
D) stimulants
E) cannabinoids

75) John is a 15-year-old patient who plays on his high school basketball team. He says he is proud to be on the team's "first string." His mother brought him to the office because he is experiencing hearing loss and has frequent spasms in his legs. Which of the following are possible causes of these symptoms?

A) GNB
B) Ecstasy
C) LSD
D) paint thinner
E) Anadrol

76) In response to your questions about social activities, Venira says she and her boyfriend have been dating for two years now, and they are very happy together. Something about her expression makes you think there might be more to the story, however. After a moment, she adds that her boyfriend, a high school football star, has been getting more and more aggressive and recently hit her during an argument. Which of the following might be the cause of this change in his behavior?

A) Ecstasy
B) Librium
C) Anadrol
D) marijuana
E) Valium

77) Using SOAP charting, where would you document measurable information?

A) Subjective data
B) Objective data
C) Assessment
D) Plan of action
E) Test results

78) Which of the following information would you place in the "P" section when using SOAP charting?

A) practitioner’s examination
B) practitioner’s diagnosis
C) patient's chief complaint
D) test results
E) patient education

79) Which of the following information would you place in the "S" section when using SOAP charting?

A) practitioner’s examination
B) practitioner’s diagnosis
C) patient's perceptions
D) test results
E) patient education

80) Which of the following would you place in the "A" section when using SOAP charting?

A) practitioner’s examination
B) practitioner’s diagnosis
C) patient's perceptions
D) test results
E) patient education

81) Which method for maintaining notes on a patient chart is arranged according to who provided the information?

A) conventional (source-oriented medical records)
B) problem-oriented medical records
C) computerized medical records
D) SOAP records
E) patient-oriented medical records

82) Which method for maintaining notes on a patient chart uses a combination of SOMR and POMR?

A) conventional (source oriented medical records)
B) problem-oriented medical records
C) computerized medical records
D) SOAP records
E) patient-oriented medical records

83) __________ are used extensively by large clinics and practices and includes the database, problem list, treatment plan, and progress notes.

A) Conventional (source-oriented medical records)
B) Problem-oriented medical records
C) Computerized medical records
D) SOAP records
E) Patient-oriented medical records

84) Which section of the health history form includes questions about and examination (by the practitioner) of all body functions?

A) chief complaint
B) history of present illness
C) past medical history
D) review of systems
E) social and occupational history

85) The section of the health history form that contains information about when the problem started and what the patient has done to treat it is the __________.

A) personal data section
B) chief complaint section
C) history of present illness section
D) past medical history section
E) family history section

86) Which section of the health history form includes questions about and examination (by the practitioner) of all body functions?

A) chief complaint
B) history of present illness
C) past medical history
D) review of systems
E) social and occupational history

87) Where on the health history form do you find the reason the patient came to visit the practitioner?

A) personal data
B) chief complaint
C) history of present illness
D) past medical history
E) family history

88) Important information about medications (including herbal and OTC) and allergies is found in which section of the health history form?

A) personal data
B) chief complaint
C) history of present illness
D) past medical history
E) social and occupational history

89) Where on the health history form do you document information taken from the administrative sheet?

A) personal data
B) chief complaint
C) history of present illness
D) social and occupational history
E) family history

90) The __________ section of the health history form gives the practitioner information about exposure to hazardous substances, sexual practices, and chemical use habits.

A) personal data
B) history of present illness
C) family history
D) past medical history
E) social and occupational history

91) Mr. Henderson denies that he is in pain, but you noticed that he grimaces when he stands up and that he moves very slowly and carefully. Which interview skill are you using?

A) effective listening
B) awareness of nonverbal cues
C) broad knowledge base
D) summarizing to form a general picture
E) doing research before the interview

92) Kenneth Little is complaining of burning when he voids. Because you suspect he has a urinary tract infection, you ask him more questions about the appearance of the urine, how often he has the urge to urinate, if he has any hesitancy, and when the symptoms started. Which interviewing skill does this demonstrate?

A) effective listening
B) awareness of nonverbal cues
C) broad knowledge base
D) summarizing to form a general picture
E) making the patient feel at ease

93) Which of the following is an ineffective way to make a patient feel at ease and should never be used?

A) use icebreakers
B) fail to maintain eye contact
C) call a patient "honey" or "sweetie"
D) ensure privacy
E) appear relaxed

94) Asking the patient "What do you think about this?" allows the patient to evaluate the situation and form an opinion. This is an example of __________.

A) clarification
B) verbalization
C) reflection
D) hypothesizing
E) probing

95) Jill Hanson is a 16-year-old patient who has come to the office complaining of lower abdominal pain. As you interview her, you notice that she seems to have difficulty concentrating on the conversation. She constantly looks toward the closed door of the exam room, and she asks you several times whether the provider is "nice." Which of the following would you suspect as the reason for Jill's behavior?

A) depression
B) physical abuse
C) substance abuse
D) aggression
E) anxiety

96) In which year did enforcement of the HIPAA act, dealing with patient’s rights, begin with penalties of up to $250,000 in fines and 10 years in jail?

A) 1992
B) 1998
C) 2001
D) 2003
E) 2005