week 1 & 2

When are open-ended questions generally most useful?
A. During sensitive area part of the interview
B. While designing the genogram
C. After several closed-ended questions have been asked
D. During the review of systems

Periods of silence during the interview can serve important purposes, such as
A. increasing the length of the visit.
B. promoting calm.
C. providing time for reflection.
D. allowing the clinician to catch up on documentation.

Mr. Franklin is speaking with you, the healthcare provider, about his respiratory problem. Mr.
Franklin says, "I’ve had this cough for 3 days, and it’s getting worse." You reply, Tell me
more about your cough. Mr. Franklin 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?
A. I’d like to hear more about your experiences. Where were you born?
B. I’ll examine you and figure out later what the problem is.
C. I don’t know what’s wrong. You could have almost any disease.
D. After 3 days, you’re tired of coughing. Have you had a fever?

After you ask a patient about her family history, she says, "Tell me about your family now."
Which response is generally most appropriate?
A. Ignore the patient’s comment and continue with the interview.
B. Ask the patient why she needs to know.
C. Tell the patient that you do not discuss your family with patients.
D. Give a brief, undetailed answer.

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
A. finish the interview as rapidly as possible.
B. ask the patient to take a deep breath and calm down.
C. continue to collect information regarding the chief complaint in an unhurried manner.
D. ask the patient if she wants to wait until another day to talk to you.

Ms. A states, "My life is just too painful. It isn’t worth it." She appears depressed. Which one
of the following statements is the most appropriate caregiver response?
A. "Try to think about the good things in life."
B. "You can’t mean what you’re saying."
C. "If you think about it, nothing is worth getting this upset about."
D. "What in life is causing you pain?"

You are collecting a history from a 16-year-old girl. Her mother is sitting next to her in the
examination room. When collecting history from older children or adolescents, they should be
A. allowed to direct the flow of the interview.
B. ignored while you address all questions to the parent.
C. given the opportunity to be interviewed without the parent at some point during the interview.
D. mailed a questionnaire in advance to avoid the need for them to talk.

When interviewing older adults, the examiner should
A. position himself or herself facing the patient.
B. speak extremely loudly, because most older adults have significant hearing impairment.
C. provide a written questionnaire in place of an interview.
D. dim the lights to decrease anxiety.

To what extent should the patient with a physical disability or emotional disorder be involved
in providing health history information to the health professional?
A. The patient should be fully involved to the limit of his or her ability.
B. The patient should be involved only when you sense that he or she may feel ignored.
C. The patient should be present during information collection but should not be addressed directly.
D. All information should be collected from past records and family members while the patient is in another room.

When taking a history, the nurse should
A. use a holistic and eclectic structure.
B. ask the patient to give you any information he or she can recall about his or her health.
C. use a chronologic and sequential framework.
D. start the interview with the patient’s family history.

When questioning the patient regarding his or her sexual history, which question should be
asked initially?
A. "Do you have any particular sexual likes or dislikes?"
B. "Do you have any worries or concerns regarding your sexual life?"
C. "Do you have any reason to think you may have been exposed to a sexually transmitted infection?"
D. "How often do you have intercourse and with whom?"

A guideline for history taking is for caregivers to
A. ask for a complete history at once so that data are not forgotten between meetings.
B. make notes sparingly so that the patient can be observed during the history taking.
C. write detailed information as stated by patients so that their priorities are reflected.
D. ask direct questions before open-ended questions so that data move from simple to complex.

Mr. D complains of a headache. During the history, he mentions his use of alcohol and illicit
drugs. This information would most likely belong in the
A. past medical history.
B. review of systems.
C. personal and social history.
D. chief complaint.

Direct questioning about domestic violence in the home should be
A. a routine component of history taking with all patients.
B. conducted only in cases in which there is a history of abuse.
C. avoided for fear of offending the patient’s partner.
D. used only when the patient is obviously being victimized.

A tool used to screen adolescents for alcoholism is the
A. CRAFFT.
B. HITS.
C. PACES.
D. CAGE.

Tom is a 16-year-old diabetic who does not follow his diet. He enjoys his dirt bike and seems
unconcerned about any consequences of his activities. Which factor is typical of adolescence
and pertinent to Tom’s health?
A. High self-esteem
B. Attachment to parents
C. Low peer support needs
D. Propensity for risk taking

Mr. Mills is a 55-year-old patient who presents to the office for an initial visit for health
promotion. A survey of mobility and activities of daily living (ADL) is part of a(n)
A. functional assessment.
B. ethnic assessment.
C. social history.
D. genetic examination.

Constitutional symptoms in the ROS refer to
A. hearing loss, tinnitus, and diplopia.
B. height, weight, and body mass index.
C. rashes, skin turgor, and temperature.
D. fever, chills, fatigue, and malaise.

JM has been seen in your clinic for 5 years. She presents today with signs and symptoms of
acute sinusitis. The type of history that is warranted is a(n) _________ history.
A. interim
B. problem or focused
C. inventory
D. complete

Which are appropriate for the interview setting with a patient? (Select all that apply.)
a. Playing music in the background
b. Ensuring comfort for all involved
c. Maintaining eye contact
d. Using a conversational tone
e. Keeping the door open
f. Removing physical barriers

Which part of the information contained in the patient’s record may be used in court?
A. All information
B. Diagnostic information only
C. Subjective information only
D. Objective information only

Ms. S reports that she is concerned about her loss of appetite. During the history, you learn
that her last child recently moved out of her house to go to college. Rather than infer the cause
of Ms. S’s loss of appetite, it would be better to
A. have her husband call you.
B. defer or omit her comments.
C. quote her concerns verbatim.
D. refer her for psychiatric treatment.

Which is an effective adjunct to document the location of findings during the recording of the
physical examination?
A. Comparison with other patients of same gender and size
B. Computer graphics
C. Comparison to previous examinations using light pen markings
D. Relationship to anatomic landmarks

The position on a clock, topographic notations, and anatomic landmarks
A. are used for noting disease progression.
B. are methods for recording locations of findings.
C. should not be used in the legal record.
D. are ways for recording laboratory study results.

Regardless of the origin, discharge is described by noting






A. associated symptoms in alphabetic order.
B. demographic data and risk factors.
C. color and consistency.
D. a grading scale of 0 to 4.

Drawing of stick figures is most useful to
A. demonstrate radiation of pain.
B. compare findings in extremities.
C. indicate consistency of lymph nodes.
D. indicate mobility of masses.

Which is an example of a problem that requires recording on the patient’s problem list?
A. Problems needing further evaluation
B. Expected findings
C. Minor variations
D. Common age variations

A problem may be defined as anything that will require
A. evaluation.
B. surgery.
C. treatment.
D. medication.

Differential diagnoses belong in the
A. physical examination.
B. assessment.
C. history.
D. plan.

Which of the following is not a component of the plan portion of the problem-oriented
medical record?
A. Differential diagnosis
B. Therapeutics
C. Diagnostics ordered
D. Patient education

Your patient returns for a blood pressure check 2 weeks after a visit during which you
performed a complete history and physical examination. This visit would be documented by
creating a(n)
A. progress note.
B. problem-oriented medical record.
C. triage note.
D. accident report.

A detailed description of the symptoms related to the chief complaint is presented in the
A. history of present illness.
B. assessment.
C. general patient information section.
D. differential diagnosis.

The effect of the chief complaint on the patient’s lifestyle is recorded in which section of the
medical record?
A. Chief complaint
B. Past medical history
C. History of present illness
D. Social history

The patient’s perceived disabilities and functional limitations are recorded in the
A. general patient information.
B. problem list.
C. history of present illness.
D. social history.

The review of systems is a component of the
A. past medical-surgical history.
B. assessment.
C. health history.
D. physical examination.

Allergies to drugs and foods are generally listed in which section of the medical record?
A. Problem list
B. Past medical history
C. Social history
D. History of present illness

Information recorded about an infant differs from that recorded about an adult, mainly
because of the infant’s
A. attention span.
B. source of information.
C. developmental status.
D. nutritional differences.

Which finding is unique to the documentation of a physical examination of an infant?
A. Prostate size
B. Liver span
C. Fontanel size
D. Thyroid position

Data relevant to the social history of older adults includes information on
A. date of last cancer screening.
B. over-the-counter medication intake.
C. family support systems.
D. previous healthcare visits.

A SOAP note is used in which type of recording system?
A. Systems review
B. Preventive care
C. Traditional treatment
D. Problem oriented

The examiner’s evaluation of a patient’s mental status belongs in the
A. physical examination.
B. history of present illness.
C. review of systems.
D. patient education.

Which format would be used for visits that address problems not yet identified in the
problem-oriented medical record (POMR)?
A. Progress note
B. Referral note
C. Comprehensive health history
D. Brief SOAP note

George Michaels, a 22-year-old patient, tells the nurse that he is here today to ―check his
allergies.‖ He has been having ―green nasal discharge‖ for the last 72 hours. How would the
nurse document his reason for seeking care?
A. GM is a 22-year-old male here for "allergies."
B. GM came into the clinic complaining of green discharge for the past 72 hours.
C. GM, a 22-year-old male, states that he has allergies and wants them checked.
D. GM is a 22-year-old male here for having "green nasal discharge" for the past 72 hours.

An image of any group that rejects its potential for originality or individuality is known as
a(n)
A. acculturation.
B. stereotype.
C. ethnos.
D. norm.

Mr. L presents to the clinic with severe groin pain and a history of kidney stones. Mr. L’s son
tells you that for religious reasons, his father wishes to keep any stone that is passed into the
urine filter that he has been using. What is your most appropriate response?
A. "We don’t know yet if your father has another kidney stone, so we must analyze this one."
B. "With your father’s permission, we will examine the stone and request that it be returned to him."
C. "The stone must be sent to the lab for examination and therefore cannot be kept."
D. "We cannot let him keep his stone because it violates our infection control policy."

The motivation of the healthcare professional to "want to" engage in the process of becoming
culturally competent, not "have to," is called
A. cultural skill.
B. cultural awareness.
C. cultural knowledge.
D. cultural desire.

Mr. Marks is a 66-year-old patient who presents for a physical examination to the clinic.
Which question has the most potential for exploring a patient’s cultural beliefs related to a
health problem?
A. "What types of symptoms have you been having?"
B. "What is your age, race, and educational level?"
C. "How often do you have medical examinations?"
D. "Why do you think you are having these symptoms?"

The definition of ill or sick is based on a
A. cultural attitude.
B. stereotype.
C. belief system.
D. cultural behavior.

A 22-year-old female nurse is interviewing an 86-year-old male patient. The patient avoids
eye contact and answers questions only by saying, ―Yeah,‖ ―No,‖ or ―I guess so.‖ Which of
the following is appropriate for the interviewer to say or ask?
A. "Are you uncomfortable talking with me?"
B. "It’s hard for me to gather useful information because your answers are so short."
C. "Does your religion make it hard for you to answer my questions?"
D. "We will be able to communicate better if you look at me."

As you explain your patient’s condition to her husband, you notice that he is leaning toward
you and pointedly blinking his eyes. Knowing that he is from England, your most appropriate
response to this behavior is to
A. ask whether he would prefer to speak to the clinician.
B. tell him that you understand his need to be alone.
C. ask whether he has any questions.
D. tell him that it is all right to be angry.

Mr. Jones is a 45-year-old patient who presents to the office. A person’s definition of illness is
likely to be most influenced by
A. race.
B. enculturation.
C. socioeconomic class.
D. age group.

As the healthcare provider, you are informing a patient that he or she has a terminal illness.
This discussion is most likely to be discouraged in which cultural group?
A. First-generation European descendants
B. Dominant Americans
C. First-generation African descendants
D. Navajo Native Americans

Which variables can intrude on successful communication? (Select all that apply.)
a. Social class
b. Gender
c. Stereotype
d. Phenotype
e. Age

Campinha-Bacote’s Process of Cultural Competence Model includes which cultural
constructs? (Select all that apply.)
a. Desire
b. Awareness
c. Thought processes
d. Skill
e. Language