Collecting Patient Data
A patient presents with right upper quadrant pain. This nurse knows that as he checks the patient into the ER, the symptoms will be documented in which part of the patients chart?
What is chief complaint
Your patient is in need of a rectal temperature. What position should he be placed in?
What is the Sims' position
Dr. Smith discussed with his patient that her LDL cholesterol did not decrease after three months. Which step of patient care process is this?
What is evaluation
The doctor listened to a patient explain her chief complaint and when her symptoms began. This will be documented in what part of the SOAP notes?
What is subjective
Teaching a patient to walk with the assistance of crutches is an example of what?
What is theraputic
Sally is admitted to the Respiratory Care Unit. The nurse needs information about her previous illnesses. What part of the patient interview is this?
What is medical history
Dakota is admitted to the outpatient area for bleeding in the mouth. The best position for the nurse to place him in is the:
What is high Fowler's position
ER doctor orders a STAT abdominal x-ray and ultrasound. This is considered which part of patient care process?
What is Planning
The respiratory therapist notes respiratory rales. This is documented in which section?
What is objective
Jody is scheduled for a follow-up appointment after sustaining a radial fracture. This is what type of service?
What is therapeutic
After assessing your patient and moving him to his room, he presents you with his insurance card for you to add to his medical record. This is considered what part of collecting patient data?
What is financial
A patient is taken to the delivery room in active labor. What is the most common position to place the patient for delivery?
What is Lithotomy
The doctor is exploring patient responses to the new clinical trial medication. This is part of which patient care process?
What is evaluation
The patient has a decubitus ulcer on the sacrum. The physician reviews the plan of action for treating this wound with the patient. This will be documented in what part of the SOAP notes?
What is plan
If a patient receives a chest x-ray to evaluate their potential for having pneumonia, the x-ray would be an example of what type of service?
What is diagnostic
While completing paperwork to admit a patient, she notes that the patient’s sister has ovarian cancer. This is considered what part of collecting patient data?
What is the Family History
In which position should a patient be placed in if her blood pressure is measured low during the assessment?
What is Trendelenburg
When the nurse carries out the orders given by the physician, this is which part of the patient care process?
What is implement
The nurse practitioner determines that Jessica has contact dermatitis. This will be documented in what part of the SOAP notes?
A rapid strep test is considered as which type of service?
While completing the patient interview, your patient states that he is currently a diabetic with chronic headaches. This is considered what part of collecting patient data?
What is Present Illnesses
The COPD patient is complaining of severe orthopnea when lying flat. Which is the best position for this patient?
What is high Fowler's
A physical therapist determines a patient's current range of motion and starts to exercise the injured joint. This is what step in the patient care process?
What is implement
"My knee hurts" would be recorded in which section of the SOAP notes?
What is subjective
An Occupational Therapist would be considered as which service?
What is therapeutic