Medical Terminology and Documentation, Exams of Nursing

Download Medical Terminology and Documentation and more Exams Nursing in PDF only on Docsity! TAUC Scribe Pretest What does the following abbreviation stand for? HPI - Answer -History of Present Illness In what body section would you document thyromegaly? A. Neck B. Neurological C. Skin, hair, nails D. Head E. Musculoskeletal - Answer -A. Neck A sensation of the room spinning is called _______. A. Lightheadedness B. Dysphagia C. Seizure D. Syncope E. Ataxia F. Vertigo - Answer -F. Vertigo Which of the following findings would be documented under the chest/lung section of the physical exam? Select all that apply. A. Guarding B. Decreased breath sounds C. Costochondral tenderness D. Accessory muscle use E. Tachycardic - Answer -B. Decreased Breath sounds C. Costochondral tenderness D. Accessory muscle use Pain radiating from the lower back down one or both legs, a form of radiculopathy is _______. A. Trismus B. Syncope C. Infarct D. Dyphagia E. Myalgia F. Sciatia - Answer -F. Sciatia Definition: What is the test in which the tendon is tapped to determine the integrity of the spinal cord and peripheral nervous system responsible for the reflex? A. Deep tendon reflexes B. Syncope C. Orientation D. Neuralgia E. Babinski Skin - Answer -A. Deep Tendon Reflexes In order for a procedure to be billable, the CPT symbol at the top left must be a ______. A. Blue triangle with checkmark C. Add a diagnosis of hypertension (HTN) Definition: What is inflammation of the cartilage that connects a rib to the sternum? A. Arthritis B. Costochondritis C. Osteomyelitis D. Pharyngitis E. Tenosynovitis - Answer -B. Costochondritis What lines the eyelids and the surface of the eye? A. Iris B. Fovea C. Lens D. Conjunctiva E. Pupil - Answer -D. Conjunctiva The uric acid panel (CHEM-13) also contains everything included in ____ plus some more tests. A. Hep A B. Liver Function Panel C. Lipid Panel D. CBC E. Cardiac Panel - Answer -B. Liver Function Panel In which body section would you document anisocoria? A. Ears B. Head C. Nose D. Eyes E. General - Answer -D. Eyes Definition: What is shortness of breath, or difficulty breathing? A. Tachypnea B. Orthopnea C. Hemoptysis D. Wheezing E. Dyspnea F. Bronchitis - Answer -E. Dyspnea Definition: What is bruising called? A. Arrhythmia B. Pallor C. Ecchymosis D. Myalgia E. Purulent F. Edema - Answer -C. Ecchymosis Definition: What is enlargement or swelling of lymph nodes? A. Lymphangitis B. Thyromegaly C. Meningimus D. Lymphadenopathy E. Trachea Midline - Answer -D. Lymphadenopathy Which of the following findings would be documented under the genitourinary of the physical exam? A. Anal Fissure B. Testicular swelling C. Adnexal tenderness D. Hypoperistalsis E. Maladourous white discharge - Answer -A. Anal Fissure B. Testicular swelling C. Adnexal tenderness E. Maladourous white discharge Which order must be selected for every patient? A. Visual Acuity B. Initial Assessment C. IV/Blood collection D. Dexamethasone 4 Mg IM E. Vitals & IV/DC F. Patient ready to discharge G. AIM COVID-19 swab - Answer -F. Patient ready to discharge What does the following abbreviation stand for: Abd? - Answer -Abdominal What does the following abbreviation stand for: BID? - Answer -Twice daily In what body section would you document carotid bruit? D. Urgency E. Rhinorrhea F. Pruritic - Answer -B. Dysuria In what body section would you document erythematous external canal? A. Nose B. Eyes C. Oral Pharynx D. Head E. Ears - Answer -E. Ears Definition: What is the hardened of soft tissue? A. Macular B. Urticaria C. Dehiscence D. Induration E. Fluctuance - Answer -D. Induration Definition: What is redness of the white part of the eye? A. Hemoptysis B. Hematuria C. Diplopia D. Photophobia E. Conjunctival Injection F. Hematochezia - Answer -E. Conjunctival Injection Definition: What is redness? A. Erythema B. Purulent C. Ecchymosis D. Myalgia E. Pallor F. Edema - Answer -A. Erythema The provider did not shine a light in the patient's eyes during the exam. What findings below are not appropriate to keep eye section of the physical exam? Select all that apply A. No scleral ictus B. No conjunctival injection C. EOMI D. PERRL E. Ptosis - Answer -D. PERRL Definition: What is an enlarged heart? A. Myocarditis B. Thyromegaly C. Hepatomegaly D. Cardiomegaly E. Splenomegaly - Answer -D. Cardiomegaly In which of the following cases would you need to document that a patient's history is relayed by an independent historian? A. The patient is an otherwise healthy adult accompanied by their spouse for comfort B. The patient is a baby accompanied by a parent C. The patient speaks another language and has a translator D. The patient is deaf and uses a phone app to communicate - Answer -B. The patient is a baby accompanied by a parent A patient brings an x-ray performed by their PCP which the provider reviews. Which is an example of what should be documented in the chart? A. No documentation is required B. Patient's x-ray not reviewed C. Outside x-ray studied reviewed and showed no acute process D. X-ray is normal - Answer -C. Outside x-ray studied reviewed and showed no acute process What does the following abbreviation stand for? LOC - Answer -Level of consciousness Definition: What is decay of tooth or cavities? A. Trismus B. Gingival Edema C. Ptyalism D. Caries E. Edentulous - Answer -D. Caries What are the routes that anesthesia may be administrated at TAUC? A. Nerve Block B. Pill C. IV E. diplopia - Answer -A. Nystagmus When a patient is diagnosed with a fracture, what additional order must always be selected? A. Walking boot B. Medications C. Crutches D. Ace wrap E. Treat Fracture Code - Answer -E. Treat Fracture Code Definition: What is tachycardia? A. High Blood Pressure B. Slow Heart Rate C. Fast Heart Rate D. Slow respiratory rate E. Fast respiratory rate F. Low blood pressure - Answer -C. Fast Heart Rate In what body section would you document cobblestone appearance? A. Eyes B. Nose C. Ears D. Head E. Oral Pharynx - Answer -E. Oral Pharynx To look for corneal abrasions, what must the provider perform? Select all that apply? A. Scleral exam B. Ptosis exam C. Nystagmus Exam D. Dilated Exam E. Fluorescein exam - Answer -E. Fluorescein exam What must be entered in the patient's chart before launching Lab Interface? A. Procedures B. Culture Collection C. Prognoses D. Diagnoses E. BMI - Answer -D. Diagnoses What is the name of the website where you can find CT reads? A. Opal B. ASMeds C. McKesson D. DocuTAP E. AVR Teleris - Answer -E. AVR Teleris Which of the types of anesthesia that can be administered at TAUC also helps constricts blood vessels to control bleeding? A. 1% lidocaine with epi B. 0.5% sensocaine C. ethochloride D. 2% lidocaine E. 1% lidocaine - Answer -A. 1% lidocaine with epi Definition: What is blood behind the tympanic membrane (ear drum)? A. TM Perforation B. Otalgia C. Strabismus D. Hemoptysis E. Hemotympanum - Answer -E. Hemotympanum Which of the following findings would be documented under the abdominal section of the physical exam? Select all that apply. A. Ataxia B. Splenomegaly C. Rovsing's sign D. McBurney's point tenderness E. Adnexal tenderness - Answer -B. Splenomegaly C. Rovsing's sign D. McBurney's point tenderness In what body section would you document strabismus? A. Ears B. Eyes C. General D. Nose E. Head - Answer -B. Eyes A. Tachycardic B. Accessory Muscle use C. Decreased breath sounds D. Costochondral tenderness E. Guarding - Answer -B. Accessory Muscle use C. Decreased breath sounds D. Costochondral tenderness What is clear nasal drainage, also referred to as a runny nose? A. Hemoptysis B. Erythema C. Fluorescein D. Cerumen E. Rhinorrhea F. Sputum - Answer -E. Rhinorrhea Which of the following are parts of the Ear? A. Pinna B. Choroid C. Epiglottis D. Eustachian Tube E. Ciliary Body - Answer -A. Pinna D. Eustachian Tube In which of the following situations would you NOT need to document a discussion regarding a medication? A. The provider tells the patient to take a smaller dose of a previously prescribed medication B. A patient refuses a prescription medication C. The patient is advised to continue a previously prescribed med D. The patient is advised to discontinue a chronic med E. The patient is started on a new med for the first time through TAUC - Answer -E. The patient is started on a new med for the first time through TAUC What is the most common manner in which anesthesia is administered for numbing of the nerves of the fingers or toes? A. Topical Spray B. Digital Block C. Oral Pill D. IV E. Local Injection - Answer -B. Digital Block Which of the following findings would be documented under the General section of the physical Exam? select all that apply A. Obese B. Diaphoretic C. Coughing D. No acute distress E. Swelling - Answer -A. Obese C. Coughing D. No acute distress Definition: What is a pinched or compressed nerve in the spine? A. Myalgia B. Snuff Box C. Gout D. Radiculopathy E. Osteomyelitis - Answer -D. Radiculopathy Which of the types of anesthesia that can be administered at TAUC topically? A. 1% lidocaine with epi B. 0.5% sensocaine C. ethyl chloride D. 2% lidocaine x E. 1% lidocaine - Answer -C. ethyl chloride In what body section would you document rales? A. Oral Pharynx B. Neurological C. Chest/Lungs D. Cardiac E. General - Answer -C. Chest/Lungs Which of the following situations always requires that a note be added to a patient's chart? Select all that apply A. The patient declines IV fluids & blood work B. The patient declines a prescription med C. The patient is blind and is brought in by their spouse D. The patient sees a specialist for a problem unrelated to their TAUC visit E. The patient has a history of hypertension and has a normal BP while at TAUC A. Inflammation of the gallbladder B. Inflammation of the pharynx C. Inflammation of the pancreas D. Inflammation of the skin E. Inflammation of the colon F. Inflammation of the liver - Answer -A. Inflammation of the gallbladder Definition: What is the loss of sensation confirmed to the area of the perineum, buttocks, and inner aspect of the thighs? A. Saddle Anesthesia B. Neuralgia C. Dysphasia D. Clonus E. Paresthesia - Answer -A. Saddle Anesthesia Which of the following would be documented under the general section of the physical exam? A. Coughing B. Diaphoretic C. Swelling D. Obese E. No acute distress - Answer -A. Coughing D. Obese E. No acute distress In what body section would you document coughing? A. Head B. General C. Chest/Lungs D. Cardiac E. Oral Pharynx - Answer -B. General ??? In what body section would document coarse breath sounds? A. General B. Cardiac C. Oral Pharynx D. Neurological E. Chest/Lungs - Answer -E. Chest/Lungs Which of the following are Medical CT scans ONLY? Select all that apply A. CT C-spine w/o IV Contrast B. CT Leg w/o IV contrast C. CT Abdomen/Pelvis with IV contrast D. CT abdomen/pelvis w/o IV contrast E. CT Neck w/ IV contrast - Answer -D. CT abdomen/pelvis w/o IV contrast E. CT Neck w/ IV contrast In what body section would you document no CVA tenderness? A. Abdominal B. General C. Cardiac D. Chest/lungs E. Musculoskeletal - Answer -A. Abdominal In which quadrant is the appendix located? A. RUQ B. LLQ C. MLQ D. RLQ E. LUQ - Answer -D. RLQ Which is an example of a diagnosis that is considered to have systemic involvement? A. Strep throat B. Conjunctivitis C. Wrist Fracture D. Pyelonephritis - Answer -D. Pyelonephritis When ordering a tetanus shot for a patient with medicare insurance, what order do you choose? A. Hep A B. Tetanus C. Tdap D. Td E. Hep B - Answer -D. Td When ordering an eye irrigation, what orders must you choose? Select all that apply A. Color B. IV tubing B. CT head w/o IV contrast C. CT Abdomen/Pelvis with IV contrast In what body section would you document no calf tenderness? A. abdominal B. neck C. musculoskeletal D. Genitourinary E. Neurological - Answer -C. musculoskeletal You must ______ before launching the Lab interface for any work comp or self pay patient. A. confirm HIPAA page is scanned B. document culture source C. print invoice D. override billing E. recheck height & weight - Answer -D. override billing The symptom is always present, never fully resolving but does increase/decrease in severity at times A. Intermittent B. Episodic C. Waxing & waning D. Transient E. Chronic F. resolved - Answer -C. Waxing & waning Definition: What is excessive accumulation of cerumen in the ear canal, however, parts of the TM are still visible? A. Ceruminosis B. Epistaxis C. Otalgia D. Friable E. Cerumen Impaction - Answer -A. Ceruminosis Definition: What is inflammation/infection of the kidneys? A. Endometriosis B. Pyelonephritis C. Hydronephrosis D. Phimosis E. Nephrolithiasis - Answer -B. Pyelonephritis A confirmed negative pregnancy test for all females ages _____ is required prior to CT. A. 14-59 B. 16-79 C. 17-69 D. 16-80 E. 13-49 - Answer -A. 14-59 In what body section would you document localized paresthesia? A. Genitourinary B. Musculoskeletal C. Neurological D. Abdominal E. Neck - Answer -C. Neurological In what body section would you document anterior cervical lymphadenopathy? A. Lymph Nodes B. Skin, Hair, Nails C. Neurological D. Head E. Musculoskeletal - Answer -A. Lymph Nodes In what body section would you document chalazion? A. Head B. General C. Ears D. Eyes E. Nose - Answer -D. Eyes In which quadrant is the spleen located? A. LUQ B. RLQ C. MLQ D. RUQ E. LLQ - Answer -A. LUQ If the basic met panel w/CK (Metlyte) is ordered, you do NOT need to order a ______. C. Gallop present E. Systolic murmur Definition: What is also called crackles? A. splinting B. Rhonchi C. Wheezing D. Rales E. Stridor - Answer -D. Rales In what body section would you document irregular rhythm? A. Musculoskeletal B. Chest/Lungs C. General D. Cardiac E. Oral Pharynx - Answer -D. Cardiac A patient is currently taking a med that causes unwanted side effects. The provider tells the patient to continue the medication, but to only take half a pill at each dose instead of a full pill. This discussion must be documented in the chart. A. True B. False - Answer -A. True Definition: What is tachycardia? A. Slow heart rate B. Low Blood pressure C. Fast respiratory rate D. Slow respiratory rate E. High Blood pressure F. Fast heart rate - Answer -F. Fast heart rate If a patient has an abrasion to the right cheek, then which of the following normal findings should always be unchecked? A. normal skin temp B. normocephalic c. no increased blood pressure d. atraumatic e. no signs of infection - Answer -D. atraumatic In what body section would you document unequal shoulder shrug? A. Neck B. Neurological C. Genitourinary D. Abdominal E. Musculoskeletal - Answer -B. Neurological In what body selection would you document chalazion? A. Eyes B. Ears C. General D. Head E. Nose - Answer -A. Eyes A patient has an ingrowing nail on their toe. The provider recommends it be removed while the patient is at TAUC, but the patient says they are seeing their PCP tomorrow and will have it done then. Which is an example of what should be documented in the chart? A. Patient told toenail must be removed today. Patient adamantly refuses, declining any and all follow up for this condition. B. Patient declines nail plate removal C. Ingrowing toenail not removed D. Patient declines ingrowing nail excision E. Patient advised to have toenail removed. Patient declines at this time, choosing to have procedure done at PCP's office tomorrow. - Answer -E. Patient advised to have toenail removed. Patient declines at this time, choosing to have procedure done at PCP's office tomorrow. Definition: Pus-like, pertaining to pus A. Pallor B. Purulent C. Ecchymosis D. Erythema E. Pruritic F Edema - Answer -B. Purulent Definition: What is abnormal coarse rattling sound heard when auscultating the lungs? A. wheezing B. rhonchi C. stridor D. splinting B. Shoulder C. Abdomen D. Knee E. Leg - Answer -A. Hand In what body section would you document congested nasal mucosa? A. Oral Pharynx B. Nose C. Eyes D. Head E. Ears - Answer -B. Nose In what body section would you document nuchal rigidity? A. Neurological B. Skin, Hair, Nails C. Head D. Neck E. Musculoskeletal - Answer -D. Neck What is the mucous secretion from the lungs which is coughed up? A. Tachypnea B. Sputum C. Rhinorrhea D. Croup E. Orthopnea F. Ecchymosis - Answer -B. Sputum Where can you find the Fluorescein Eye Strips Order? A. Ortho tab B. Misc/other tab C. Med tab D. Gen tab E. Labs tab - Answer -B. Misc/other tab Definition: What are hyperactive bowel sounds (increased)? A. Hyperperistalsis B. Hypotension C. Obturator Sign D. Hypertension E. Hypoperistalsis - Answer -A. Hyperperistalsis In which quadrant is the gallbladder located? A. RLQ B. RUQ C. LLQ D. LUQ E. MLQ - Answer -B. RUQ Which of the following are parts of the Adult Skull? A. occipital B. temporal C. parietal D. navicular E. humerus - Answer -A. occipital B. temporal C. parietal X-ray readings must be entered into _______. Select all that apply A. Opal B. ASMeds C. X-ray tab in Docu-tap D. Procedure note in docu-tap E. Ct tab in docu-tap - Answer -A. Opal C. X-ray tab in Docu-tap In what body section would you document patient appears to be in moderate pain? A. Head B. Neurological C. Muscuoskeletal D. General E. Chest/Lungs - Answer -D. General Where can you find the orthostatic vitals order? A. Ortho tab B. Misc/other tab C. Med tab E. Oral Pharynx - Answer -A. Nose Where can you find the splint orders? A. Ortho tab B. Misc/other tab C. Med tab D. Gen tab E. Labs tab - Answer -A. Ortho tab What do you type in the Notes bar when ordering at CT? A. "See Scan" B. "Name of Ordering Physician" C. "Type of CT" D. " (with or without) contrast" E. " (number of) Ct's - Answer -A. "See Scan" Which Ultrasound would be ordered to investigate veins in the arms or legs? A. US Pelvis Complete B. US Extremity Veins Limited C. US Abdomen Limited D. US Scrotum and Contents E. US Extremity Veins Complete - Answer -B. US Extremity Veins Limited For coding, the second to last number should be a 0 if __________. A. The pt has not been to a hospital in the last 3 years B. The pt has a PCP C. The pt has been to a TAUC recently D. The pt has never seen a PCP E. The pt has never been to TAUC - Answer -E. The pt has never been to TAUC How many lobes are in the left Lung? A. 1 B. 2 C. 3 - Answer -B. 2 Definition: What is extreme sensitivity to light? A. Neuralgia B. Vertigo C. Diplopia D. Photophobia E. Raccoon Eyes F. Trismus - Answer -D. Photophobia Definition: Hypertension is ____ A. Slow respiratory rate B. High Blood Pressure C. Fast Resp rate D. Fast heart rate E. Low blood pressure F. slow heart rate - Answer -B. High Blood Pressure Inadequate blood supply to an organ or part of the body is _____ A. Infarct B. Thrombus C. Pulmonary Embolism D. Ischemia E. Trismus F. Embolism - Answer -D. Ischemia Definition: Tachypnea is _____ A. Slow respiratory rate B. High Blood Pressure C. Fast Resp rate D. Fast heart rate E. Low blood pressure F. slow heart rate - Answer -C. Fast Resp rate Which of the following would be documented under the nose section of the physical exam? A. polyp to nasal mucosa B. clear PND C. hemotympanum D "Hot potato" voice E. bloody nasal discharge - Answer -A. polyp to nasal mucosa E. bloody nasal discharge Infection (infiltrate) in the lung tissue causes lung inflammation, cough, and fever is _________ A. COPD In what body section would you document hemorrhoids? A. Cardiac B. General C. Genitourinary D. Musculoskeletal E. Abdominal - Answer -C. Genitourinary What do you type in the notes bar when ordering a US? A. "Type of US" B. "[Qty of] USs" C. "[With or Without] Contrast" D. "Name of Ordering Provider" E. "See Scan" - Answer -E. "See Scan" 6) In what body section would you document pectus excavatum? A. Oral Pharynx B. General C. Neurological D. Cardiac E. Chest/Lungs - Answer -E. Chest/Lungs 7) If a walking boot is being ordered, verify that you ALWAYS note _________. (Select all that apply) A. tight or loose B. short or tall C. wide or narrow D. color E. hardness or softness - Answer -B. short or tall In what body section would you document asymmetrical smile? A. Musculoskeletal B. Genitourinary C. Neurological D. Neck E. Abdominal - Answer -C. Neurological In what body section would you document pharyngeal erythema? A. Ears B. Eyes C. Head D. Oral pharynx E. Nose - Answer -D. Oral pharynx 1) In what body section would you document limited ROM? A. Genitourinary B. Musculoskeletal C. Neurological D. Cardiac E. Abdominal - Answer -B. Musculoskeletal Definition: What is the Impairment of language affecting the production or comprehension of speech due to injury to the brain? A. Nocturia B. Syncope C. Vertigo D. Aphasia E. Malaise F. Ataxia - Answer -D. Aphasia In what body section would you document pronator drift? A. Genitourinary B. Musculoskeletal C. Abdominal D. Neck E. Neurological - Answer -E. Neurological Which of the following findings would be documented under the Neck section of the physical exam? A. Positive Homan's sign B. Positive McMurray test C. Positive Kernig's sign D. Scoliosis E. JVD - Answer -C. Positive Kernig's sign E. JVD In what body section would you document urticaria? A. Skin, Hair, Nails B. General C. Eyes D. Oral Pharynx E. Head - Answer -A. Skin, Hair, Nails Which of the following findings would be documented under the Psychiatric section of the physical exam?