Chapter 36
Patient Interview and History
Multiple Choice Questions
1. | Which of the following is charted as subjective data?
B. | Practitioner’s examination |
C. | Patient's chief complaint |
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2. | The practitioner’s diagnosis or impression of the patient’s condition is the ____.
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3. | Which of the following information would be documented under the plan of action?
A. | Medications prescribed and tests to be done |
C. | Patient's chief complaint |
D. | Results of the physician's examination |
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4. | 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 |
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5. | 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 |
C. | Asking open-ended questions |
D. | Focusing on the patient |
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6. | 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 |
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7. | "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 |
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8. | "You seem to be making progress, don't you agree?" is an example of which method of collecting patient data?
A. | Asking leading questions |
C. | Challenging the patient |
D. | Asking open-ended questions |
E. | Encouraging the patient to take the lead |
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9. | Which of the following offers the patient little freedom to explain his answers and requires only yes-or-no answers?
B. | Agreeing or disagreeing with the patient |
C. | Asking leading questions |
D. | Asking closed-ended questions |
E. | Mirroring the patient's responses |
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10. | 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. |
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11. | 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 |
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12. | 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 |
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13. | Which of the following are other names for cocaine?
D. | Angel dust, rocket fuel |
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14. | Angel dust is also known as ____.
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15. | 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 |
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16. | 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 physician |
D. | telling him to calm down |
E. | allowing him to describe his feelings |
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17. | Which of these patient behaviors is a classic symptom of depression?
C. | Obsession with exercising |
D. | Anxiety about entering the health-care system |
E. | Sleeping soundly at night |
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18. | The need for ____ in the medical record makes it essential that medical terminology and precise descriptions are used when charting.
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19. | 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. |
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20. | 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. |
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21. | 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. |
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22. | 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. |
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23. | 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 |
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24. | 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 |
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25. | 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 |
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26. | 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 |
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27. | 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 |
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28. | 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 |
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29. | 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 |
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30. | 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 |
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31. | 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 |
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32. | 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 |
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33. | An increased heart rate, confusion, anxiety, and paranoia are effects of which of the following drugs?
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34. | A decreased heart rate and blood pressure, drowsiness, and poor concentration are effects of ____.
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35. | 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?
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36. | Alternating euphoria and apprehension is an effect of ____.
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37. | 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?
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38. | 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?
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39. | Using SOAP charting, where would you document measurable information?
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40. | Which of the following information would you place in the "P" section when using SOAP charting?
A. | Physician's examination |
C. | Patient's chief complaint |
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41. | Which of the following information would you place in the "S" section when using SOAP charting?
A. | Physician's examination |
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42. | Which of the following would you place in the "A" section when using SOAP charting?
A. | Physician's examination |
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43. | 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 |
E. | Patient-oriented medical records |
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44. | 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 |
E. | Patient-oriented medical records |
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45. | ____ 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 |
E. | Patient-oriented medical records |
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46. | Which section of the health history form includes information about the health of the patient's family?
D. | Social and occupational history |
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47. | 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 ____.
B. | chief complaint section |
C. | history of present illness section |
D. | past medical history section |
E. | family history section |
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48. | Which section of the health history form includes questions about and examination (by the practitioner) of all body functions?
B. | History of present illness |
E. | Social and occupational history |
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49. | Where on the health history form do you find the reason the patient came to visit the practitioner?
C. | History of present illness |
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50. | Important information about medications (including herbal and OTC) and allergies is found in which section of the health history form?
C. | History of present illness |
E. | Social and occupational history |
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51. | Where on the health history form do you document information taken from the administrative sheet?
C. | History of present illness |
D. | Social and occupational history |
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52. | The ____ section of the health history form gives the practitioner information about exposure to hazardous substances, sexual practices, and chemical use habits.
B. | history of present illness |
E. | social and occupational history |
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53. | 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?
B. | Awareness of nonverbal cues |
D. | Summarizing to form a general picture |
E. | Doing research before the interview |
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54. | 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?
B. | Awareness of nonverbal cues |
D. | Summarizing to form a general picture |
E. | Making the patient feel at ease |
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55. | Which of the following is an ineffective way to make a patient feel at ease and should never be used?
B. | Fail to maintain eye contact |
C. | Call a patient "honey" or "sweetie" |
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56. | 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 ____.
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57. | 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 doctor is "nice." Which of the following would you suspect as the reason for Jill's behavior?
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Fill in the Blank Questions
58. | A subjective statement made by a patient describing the patient's most significant symptoms or signs of illness is the patient's ________.
________________________________________ |
59. | Effective ________ means hearing what the patient says, thinking about it, and responding appropriately.
________________________________________ |
60. | The patient's facial expressions and body language are examples of ________ communication.
________________________________________ |
61. | You must have a broad ________ base to be able to ask questions that will elicit the most meaningful information about the patient.
________________________________________ |
62. | At the end of an interview, you should ________ the information the patient provided and repeat it back to him for verification.
________________________________________ |
63. | Patient interviews should be conducted in ________ and without interruptions.
________________________________________ |
64. | Only the licensed practitioner can make a(n) ________, based on the patient’s symptoms and complaints.
________________________________________ |
65. | The method of collecting patient data that requires more than a yes-or-no answer is asking _________ questions.
________________________________________ |
66. | The method of collecting data that allows you to determine the patient's knowledge of the situation is asking ________ questions.
________________________________________ |
67. | Restating as exactly as possible what the patient said is an example of _______ the patient’s responses.
________________________________________ |
68. | Stating what you believe the patient is suggesting by his response is a technique known as _______.
________________________________________ |
69. | 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.
________________________________________ |
70. | "White coat syndrome" is a type of _______ related to seeing a medical provider.
________________________________________ |
71. | When the patient shows signs of _______, every effort should be made to help the patient relax and release or reduce these feelings.
________________________________________ |
72. | Classic symptoms of ________ are profound sadness and fatigue.
________________________________________ |
73. | Signs of substance abuse or ________ can be mistaken for depression.
________________________________________ |
74. | Taking larger-than-prescribed doses of a medication is an example of _______.
________________________________________ |
75. | A physical or psychological dependence on a substance is called a(n) ________.
________________________________________ |
76. | An unlikely explanation for an injury may be a sign of ________.
________________________________________ |
77. | If you suspect a patient has been abused, you must report it to your supervisor or the ________.
________________________________________ |
78. | Most patient charts are arranged with the entries in reverse _______ order.
________________________________________ |
79. | The thoughts, feelings, and perception of a patient are _______ data when you document using the SOAP format.
________________________________________ |
80. | Data that is readily apparent and measurable is _______ data.
________________________________________ |
81. | The practitioner's diagnosis or impression of the patient's problem is documented in the _______ section of the SOAP format chart notes.
________________________________________ |
82. | 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.
________________________________________ |
83. | Information is arranged according to who provided the information in _______ or source-oriented medical records.
________________________________________ |
84. | Conditions or problems are identified by a number throughout the record until the problem is resolved in _______ medical records.
________________________________________ |
85. | When an office uses _______ medical records, the records are accessible at any time and combine SOMR and POMR methods.
________________________________________ |
86. | 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.
________________________________________ |
87. | The ________ interview technique will help you remember the types of questions that are appropriate for the patient's condition.
________________________________________ |
88. | Many offices use a variation of the _______ note to document routine follow-ups of established patients with ongoing conditions such as hypertension or arthritis.
________________________________________ |
89. | The patient's name, Social Security number, and birth date are documented in the _______ data section of the health history form.
________________________________________ |
90. | 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.
________________________________________ |
91. | 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.
________________________________________ |
92. | The _______ medical history includes important information about medications and allergies.
________________________________________ |
93. | The use of alcohol, tobacco, recreational drugs, or other chemical substances is documented in the _______ history.
________________________________________ |
Multiple Choice Questions
94. | 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?
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Fill in the Blank Questions
95. | The Joint Commission (TJC) and the ______________ (ISMP) are two organizations whose mission includes promotion of patient safety by publishing the official “Do Not Use” list of abbreviations in an effort to reduce medical errors.
____________________________________________________________ |
96. | When using the PQRST interview technique, the S stands for _________.
________________________________________ |