Download Scribe America final exam (retake)-with 100% verified solutions-2023-2024 .docx and more Exams Nursing in PDF only on Docsity! Scribe America final exam (retake)- with 100% verified solutions-2023- 2024 What do you document for a syncope patient? How do you feel before? How do you feel during? How do you feel after? How do you feel now? When a physician does a check for a pronator drift, and checks the CN - 111, where should you document the results? Neurological / Cerebellar / Coordination Chest pain (bonus question) MI Aortic Dissection Lower abdomen (bonus question) cholecystitis ruptured appendicitis Dynspena (bonus question) Pneumothorax pulmonary embolism Test(s) done to diagnose SBO -CT A/P with PO -acute abdominal series (AAS) What's PHI? -anything that can expose the patient's identity -name, date, reason for visit, etc. Test(s) done to diagnose appendicitis CT A/P with PO contract Test(s) done to diagnose cholecystitis abdominal US of RUQ Test(s) done to diagnose meningitis LP Test(s) done to diagnose hemorrhagic CVA CT Head LP Test(s) done to diagnose CHF CXR Elevated BNP Test(s) done to diagnose PE CTA Chest/ VQ scan (D-dimer ONLY rules out) What is it called when you get your kidney removed? nephrectomy You see a fellow scribe helping a patient up from their bed, what do you do? Tell your chief scribe! physician says right wrist is fine, what do you write? Right radial pulse 2+ RLQ pain indicates appendicitis RUQ pain indicates cholecystitis LLQ pain indicates diverticulitis -vision Pt is experiencing artery blockage of blood to the brain causing lack of O2. What would your Dx be? Ischemic CVA EOMI extraocular movements intact Elementsof ROS/HPI Onset timing location quality severity modifying factors associated symptoms context what is the MOST important thing to document in the HPI (the pt has been giving lots of complaints and its difficult to find the "key point") accurate chronology What is the procedure called when the pt gets their "neck artery cleaned"? carotid endarterectomy Pt broke their leg, what test would you document? Lower Extremity X-ray What is it called when pt has their tubes tied? bilateral tubal ligation (female) vassectomy (male) Physician takes EKG prior, then enters room and listenes to the pt's heart. He concludes that the pace is irregularly irregular. What do you document? AFib breast removal mastectomy partial colon removed Partial colectomy Appendix removed appendectomy gallbladder removed cholecystectomy stomach stapled bariatric surgery uterus removed hysterectomy spell out c-section cesarean section runny nose rhinorrhea wet crackling in lungs rhonchi bruise ecchymosis