Chapter 04: Clinical Reasoning

Multiple Choice

1. After the subjective and objective data have been prioritized, the next step is to: a. order laboratory tests. b. formulate a problem list. c. establish the diagnosis. d. initiate therapy. e. initiate appropriate consultations.

ANS: B

Formulate a problem list problems as specifically as possible. Identify and list the signs and m m a cia ed i h each f a ie c ce a ell a ab mali ie di c e ed during the physical examination.

TOP: Discipline: Behavioral Science MSC: Organ System: General

2. New symptoms or findings of unknown etiology are: a. problems to be noted on the problem list. b. deferred for subsequent visits. c. diagnosed before physical examination. d. reserved for specialists. e. all ed he i g .

ANS: A

New findings of unknown causes are added to the problem list, but do not let them become a ed he i g ha di ac a e i f m he ce al i e .

TOP: Discipline: Behavioral Science MSC: Organ System: General a. Always unifying your findings into one diagnosis b. Making maximal use of laboratory tests c. Using first assumptions d. Using algorithms e. Relying on intuition

3. Which of the following is an accepted method of making a diagnosis?

ANS: D

Methods to make a diagnosis include recognizing patterns, sampling the universe, and using algorithms. Unifying all of your findings into one diagnosis is not always possible. More than one disease process can exist at one time in the same patient. Do not rely on intuition, extensive use of laboratory findings, or always going with your first assumptions.

TOP: Discipline: Behavioral Science MSC: Organ System: General

4. Medical decision making requires a balance between: a. speculation and feelings. b. opinions and beliefs. c. knowledge and superstition. d. Mechanism and probability. e. trust and suspicion.

ANS: D

Medical decision making must have a balance between mechanism and probability (certainty in knowledge is impossible).

TOP: Discipline: Behavioral Science

MSC: Organ System: General

5. When evaluating results of laboratory tests, a test that is highly sensitive implies that the test: a. suggests that a disease is present when it actually is not. b. will not have any false-positive results. c. suggests that a disease is absent when it is absent. d. is able to correctly identify for the disease being tested. e. is able to confirm a diagnosis even when the disease is not present.

ANS: D

Testing that is sensitive is a test that will be able to correctly identify persons with the disease that the test has been designed to test for. Positive results are more likely to be positive for the disease. High specificity suggests the ability of an observation to identify correctly those who do not have the disease.

TOP: Discipline: Biostatistics

MSC: Organ System: General

6. A specific test is one that has the ability to: a. correctly identify those who have the disease. b. correctly identify those who do not have the disease. c. be exclusively used to make a diagnosis. d. suggest the presence of a disease that is not present. e. exclude competing explanations for another test finding.

ANS: B

The specificity of a test is determined by its ability to identify those who do not have the disease that the test is designed to test for. Negative results are more likely to be valid.

TOP: Discipline: Biostatistics

MSC: Organ System: General a. sensitivity positive specific b. negative specific c. positive predictive d. negative predictive e. true negative

7. The proportion of persons with an observation characteristic of a disease that have the disease is known as _____ value.

ANS: C

A positive predictive value is defined as the proportion of persons thought to have a disease who actually have the disease.

TOP: Discipline: Biostatistics

MSC: Organ System: General a. Presumptive diagnosis b. Subspecialty consultation c. Diet modification d. Follow-up visit e. Patient education

8. Which of the following is not a component of a management plan?

ANS: A

The management plan details what you are going to do about a patient problem such as subspecialty consultations, diet modifications, follow-up visits, and any necessary patient education.

TOP: Discipline: Behavioral Science MSC: Organ System: General

9. When determining priorities for planned actions, the practitioner should: a. address problems in the order of their chronologic development. b. consider whether the patient is concerned about a particular problem before addressing it. c. ig e he a ie cial a d ec mic ci c m a ce . d. address the most urgent problem first. e. e e c ide if he c f ca e ill im ac he a ea f he a ie life.

ANS: D

In developing patient care plans, priority should be given to the most life threatening and ge h ical eed f he a ie . The f c add e i g he a ie cial a d economic circumstances and whether the cost of care will impact other areas f he a ie life.

TOP: Discipline: Behavioral Science MSC: Organ System: General

10. Bits of information that are distracting and draw your thinking away from central issues are referred to as: a. Bayes theorem. b. true negatives. c. mechanism and probability d. red herrings. e. false negatives.

ANS: D

Beware of red herrings, the bits of information that are distracting and draw yo ur thinking away from central issues. Critically evaluate unexpected or unusual findings but do not let them distort full consideration of all you have learned.

TOP: Discipline: Behavioral Science MSC: Organ System: General

11. In issues surrounding ethical decision making, beneficence refers to the: a. appropriate use of medical resources. b. care provider acting as a father or mother figure. c. care provider knowing what is best for the patient. d. need to avoid harming the patient. e. need to do good for the patient.

ANS: E

The definition of beneficence is to do good, not being paternalistic, and the need to avoid harm refers to nonmaleficence. Utilitarianism is the appropriate use of resources for the greater good of the larger community.

TOP: Discipline: Behavioral Science MSC: Organ System: General

12. The e m de i g he ca egi e eed d ha m he a ie i : a. autonomy. b. deontologic imperative. c. nonmaleficence. d. utilitarianism. e. beneficence.

ANS: C

The definition of nonmaleficence is to do no harm.

TOP: Discipline: Behavioral Science MSC: Organ System: General a. Inform the patient of the treatment plan. b. Give the patient detailed written instructions regarding the treatment plan. c. Inform the patient that the plan has been tailored to his needs. d. Inform the patient of treatment options and possible results. e. Lead the patient to an understanding that you know the best treatment option.

13. Which of the following is initially a ia e i he ma ageme f a a ie diag ed problem?

ANS: D

A i i ial a ach a a ie blem h ld all f he g ea e a ie a m a d should promote patient participation. The well-informed patient is better able to exercise autonomy. Only informing the patient of treatment options and possible results does this.

TOP: Discipline: Behavioral Science MSC: Organ System: General

Multiple Choice

1. During the course of the interview, you should: a. take no notes of any kind. b. take brief written notes. c. take detailed written notes. d. repeat pertinent comments into a Dictaphone. e. interrupt the interview to formulate your thoughts.

ANS: B

During the interviewing process, it is important to maintain eye contact with the patient and to spend as little time as possible looking at your notes, so brief written notes are more practical. Later you can go back and formulate a well-versed history by linking all the pieces together.

TOP: Discipline: Behavioral Science MSC: Organ System: General

2. Subjective and symptomatic data are: a. documented in your assessment. b. not mentioned in the legal chart. c. placed in the history sections. d. recorded with the examination technique. e. documented with the findings.

ANS: C

Subjective data, as well as symptomatic data, should not be part of the physical examination findings; rather, their documentation is appropriate for the history portion.

TOP: Discipline: Behavioral Science MSC: Organ System: General

3. The quality of a symptom, such as pain, is subjective information that should be: a. deferred until the cause is determined. b. described in the history using a 0 to 10 scale. c. placed in the past medical history section. d. placed in the history with objective data. e. interpreted in light of your physical findings.

ANS: B

Pain is subjective, and only the patient can rate the perceived severity. Pain, therefore, should be recorded in the history using a 0 to 10 scale.

TOP: Discipline: Behavioral Science MSC: Organ System: General

4. Drawing of stick figures is most useful to: a. compare findings in the extremities. b. demonstrate radiation of pain. c. indicate organ enlargement. d. indicate mobility of masses. e. indicate consistency of lymph nodes.

ANS: A

Simple drawings, such as stick figures, are more practical illustrations for findings in the extremities. Radiation of pain, organ enlargement, consistency of lymph nodes, and mobility of masses would not be adequately described by such simple drawings.

TOP: Discipline: Behavioral Science MSC: Organ System: General a. Common age variations b. Expected findings c. Findings of unknown origin d. Minor variations e. Only findings that have a clear etiology

5. Which of he follo ing is an e ample of a problem req iring recording on he pa ien s problem list?

ANS: C

Any problem is worth noting on the patient problem list even if the etiology or significance is unknown. Common age variations, expected findings, and minor variations within normal limits should not be classified as problems.

TOP: Discipline: Behavioral Science MSC: Organ System: General

6. Differential diagnoses belong in the: a. history. b. physical examination. c. assessment. d. plan. e. laboratory data.

ANS: C

Differential diagnoses for problems that have not been diagnosed are placed in the assessment category for each problem. The differentials are prioritized, and contributing factors are identified.

TOP: Discipline: Behavioral Science MSC: Organ System: General

7. When recording assessments during the construction of the problem-oriented medical record, the examiner should: a. combine all data into one assessment. b. create an assessment for each problem on the problem list. c. create an assessment for every abnormal physical finding. d. create an assessment for every symptom presented in the history. e. create an assessment for each abnormal laboratory finding.

ANS: B

After the examiner has a list of problems constructed, an assessment is made for each unique problem.

TOP: Discipline: Behavioral Science MSC: Organ System: General

8. 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. incident report. c. problem-oriented medical record. d. triage note. e. new problem list.

ANS: A

A second visit with the clinician is always recorded on a progress note, noting any updates to the condition.

TOP: Discipline: Behavioral Science MSC: Organ System: General a. Chief complaint b. History of present illness c. Past medical history d. General patient information e. Social history

9. The effec of he chief concern on he pa ien s lifes le is recorded in hich sec ion of he medical record?

ANS: B

The effec of he pa ien s complain on his or her c rren e er da lifes le or ork performance is recorded in the history of present illness.

TOP: Discipline: Behavioral Science MSC: Organ System: General

10. The pa ien s perceived disabilities and functional limitations are recorded in the: a. problem list. b. general patient information. c. social history. d. review of systems. e. past medical history.

ANS: E

Pas medical his or con ains informa ion abo he pa ien s life ime as ell as disabili ies or functional limitations that alter activities of daily living.

TOP: Discipline: Behavioral Science MSC: Organ System: General

11. The review of systems is a component of the: a. physical examination. b. health history. c. assessment. d. past medical and surgical history. e. personal and social history.

ANS: E

Review of systems relates health history according to physical systems and is related just before the actual physical examination.

TOP: Discipline: Behavioral Science MSC: Organ System: General a. General patient information b. Past medical history c. Social history d. Problem list e. History of present illness

12. Allergies to drugs and foods are generally listed in which section of the medical record?

ANS: B

The past medical history section contains information such as drugs, foods, and environmental allergies.

TOP: Discipline: Behavioral Science MSC: Organ System: General

13. Objective data are usually recorded: a. by body systems. b. in the history. c. subsequent to the assessment and plan. d. before the health history. e. in the problem list.

ANS: A

All objective data are recorded by body systems and anatomic locations.

TOP: Discipline: Behavioral Science MSC: Organ System: General

14. Information recorded about an infant differs from that of an adult, mainly because of the infan s: a. attention span. b. developmental status. c. nutritional differences. d. source of information. e. limited past medical history.

ANS: B

The organi a ional s r c re of an infan s record is differen beca se he infan s c rren and future health is referenced in terms of developmental status.

TOP: Discipline: Behavioral Science MSC: Organ System: General a. Family b. General patient information c. Personal and social d. Present problem e. Past medical

15. In which section of the newborn history would you find details of gestational assessment and extrauterine adjustment data?

ANS: D

For a ne born, he foc s of recorded informa ion is he de ails of he mo her s pregnanc , he gestational development, and events occurring since birth. These data are recorded in the present problem section of the history.

TOP: Discipline: Behavioral Science MSC: Organ System: General

16. Data relevant to the social history of older adults include information on: a. family support systems. b. extra time to assume positions. c. over-the-counter medication intake. d. date of last cancer screening. e. previous healthcare visits.

ANS: A

The social history of older adults includes community and family support systems. Healthcare visits, medications, cancer screenings, and extra time to assume positions for the physical examination are not part of the social history.

TOP: Discipline: Behavioral Science MSC: Organ System: General a. Preventive care b. Pedigree c. Systems review d. Traditional treatment e. Problem oriented

17. A SOAP note is used in which type of recording system?

ANS: E

A SOAP note, which includes subjective problem data, objective problem data, assessment, and plan, is a type of recording system that has a problem-oriented style.

TOP: Discipline: Behavioral Science MSC: Organ System: General

18. The e aminer s e al a ion of a pa ien s men al s a s belongs in he: a. history of present illness. b. review of systems. c. physical examination. d. patient education. e. problem list.

ANS: C

Mental status assessment, including cognitive and emotional stability and speech and language, is part of the physical examination. Anything subjective is part of the review of s s ems and hose findings ha are objec i e are par of he pro ider s assessmen .

TOP: Discipline: Behavioral Science MSC: Organ System: General a. Review of systems b. Percussion c. Palpation d. Auscultation e. Inspection

19. When recording physical findings, which data are recorded first for all systems?

ANS: E

Physical assessment for all systems begins with inspection.

TOP: Discipline: Behavioral Science MSC: Organ System: General

20. Regarding ano her pro ider s doc men ed ork, i : a. is not relevant in a legal proceeding. b. will not affect clinical decisions. c. may be copied verbatim into your documentation. d. must be attributed to the source if entered. e. does not affect patient care.

ANS: D

I is naccep able o cop o her pro iders doc men ed ork (e.g., his or taken, examination performed, or thought processes outlined) and enter it into your own documentation as if you did he ork. Te copied from ano her person s no e m s al a s be a rib ed o he so rce. This is not only an important concept in a legal proceeding, but it is also critical for safe patient care.

TOP: Discipline: Behavioral Science MSC: Organ System: General a. U (unit) b. qd (daily) c. MS (morphine sulfate) d. All of the above e. None of the above

21. Which of the following abbreviations is approved by The Joint Commission on Accreditation of Hospitals?

ANS: B

The Join Commission has iden ified impro ing comm nica ions among caregi ers as a pa ien safe goal. Cer ain abbre ia ions ha e been placed on a do no se lis hen an error in misreading the abbreviation could cause harm. All of the above abbreviations are on he do no se lis .

TOP: Discipline: Behavioral Science MSC: Organ System: General

Chapter 06: Vital Signs and Pain Assessment

Multiple Choice

1. Body temperature is regulated by the: a. thalamus. b. hypothalamus. c. medulla. d. pons. e. cerebellum.

ANS: B

Body temperature is regulated by the hypothalamus.

TOP: Discipline: Pathophysiology MSC: Organ System: General a. Exogenous pyrogens b. Vasoconstriction c. Shivering d. Vasodilation e. Prostaglandins

2. Which of the following is not involved in increasing body temperature?

ANS: D

Body cooling occurs by vasodilation, which increases heat loss through the skin and evaporation of perspiration.

TOP: Discipline: Pathophysiology MSC: Organ System: General a. Chronic pain b. Neuropathic pain c. Acute pain d. Acute inflammation e. Surgery

3. Which of the following is most closely related to damage or dysfunction of the central or peripheral nervous system?

ANS: B

Neuropathic pain is a long-term pain associated with damage or dysfunction of the central or peripheral nervous system (e.g., amputation, complex pain syndrome).

TOP: Discipline: Pathophysiology MSC: Organ System: General

4. Nociceptors transmit pain impulses from the periphery along A-delta and C-polymodal fibers to the: a. posterior horn of the spinal cord. b. hypothalamus. c. cerebellum. d. dorsal horn of the spinal cord. e. pons.

ANS: D

Pain impulses travel from the site of injury to the dorsal horn of the spinal cord and then through the ascending spinal tracts to the thalamus and cerebral cortex.

TOP: Discipline: Pathophysiology MSC: Organ System: General a. Low body surface area for weight b. Thicker skin c. Limited ability to cope with cold stress d. Higher pulse rate e. Lower blood pressure

5. Which of the following make infants more susceptible to hypothermia?

ANS: C

Infants are more susceptible to hypothermia because of their large ratio of body surface area to weight, thinner skin, and limited ability to cope with cold stress. Infants have a higher pulse rate and lower blood pressure than adults, but this is unrelated to hypothermia.

TOP: Discipline: Pathophysiology MSC: Organ System: General

6. A 5-year-old is complaining of nondescripti e bell pain. Your ne t action should be to ask him to: a. point a finger to the spot that hurts. b. draw a circle around the area that hurts. c. use a metaphor to describe the pain. d. identify what makes the pain worse. e. allo him to use a pain-o-meter.

ANS: A

Asking the child to point to the area of pain can help communicate a more precise location. The other choices are not appropriate for the age of the child.

TOP: Discipline: Behavioral Science MSC: Organ System: General

7. During pregnancy, all of the following may be related to back pain except: a. lax pelvic ligaments. b. weight gain. c. hyperlordosis. d. anterior tilt of the pelvis. e. lower blood pressure.

ANS: E

Blood pressure commonly decreases beginning at about 8 weeks of gestation, gradually falling until a low point is reached at midpregnancy, but this is unrelated to the back pain some women experience during pregnancy.

TOP: Discipline: Pathophysiology MSC: Organ System: General

8. The value of the use of scales for patients to rate their pain intensity is that: a. the emotional responses are factored in. b. correlation ith others e pectations is achie ed. c. the patient s response to therapy can be documented. d. subjective responses are eliminated. e. the patient s perception is minimi ed.

ANS: C

The use of scales permits the very important day-to-day documentation of the response to therap . Although the patient s perception is the controlling variable, the patient is still giving a subjective measurable response.

TOP: Discipline: Behavioral Science MSC: Organ System: General

9. A pain scale that is reliable and valid for children is the: a. pain-o-meter scale. b. pain-rating instrument scale. c. numeric pain intensity scale. d. Wong/Baker Faces Rating Scale. e. descriptive pain intensity scale.

ANS: D

The Wong/Baker Faces Rating Scale and the Oucher Scale are examples of pain scales that are reliable and valid for use with children.

TOP: Discipline: Behavioral Science MSC: Organ System: General a. Facial grimacing b. Grunting or groaning c. Body movements d. Reluctance to be moved e. Patient s report of the pain

10. Which is the most reliable indicator of a patient s pain?

ANS: E

The patient s report of pain is the most reliable indicator of pain and should be believed even when observed behaviors do not seem to correspond.

TOP: Discipline: Pathophysiology MSC: Organ System: General a. Toddlers b. Premature infants c. Neonates d. Adolescents e. Older adults

11. Which of the following groups has the greatest variation in pulse rate?

ANS: B

The ne born s pulse rate is more variable than that of toddlers, adolescents, and older adults. The variation is greatest around the time of birth and is even more marked in premature infants.

TOP: Discipline: Pathophysiology MSC: Organ System: General a. 5% to 10% b. 10% to 30% c. 40% to 60% d. 60% to 80% e. 80% to 100%

12. The heart rate of a pregnant woman may increase to a level at term that is _____ higher than normal.

ANS: B

The heart rate of a pregnant woman gradually increases throughout pregnancy until it is 10% to 30% higher at term.

TOP: Discipline: Pathophysiology MSC: Organ System: General

13. Hypertension in a pregnant woman (blood pressure reading greater than or equal to 160 mm Hg systolic or 110 mm Hg diastolic) is one sign of: a. a normal pregnancy. b. a nulliparous woman. c. preeclampsia. d. a multiparous woman. e. Braxton Hicks contractions.

ANS: C

A gradual increase in blood pressure is common from the second to the third trimester. However, hypertension in this range may be a sign of preeclampsia. Braxton Hicks contractions are sporadic uterine contractions that start at around 6 weeks of pregnancy and are not associated with gestational hypertension or preeclampsia.

TOP: Discipline: Pathophysiology MSC: Organ System: General

14. Blood pressure may increase during the process of aging caused by: a. increasing vagal tone. b. decreasing cardiac output. c. diminished tolerance to pain. d. increasing stiffness of the blood vessels. e. decreasing vascular resistance.

ANS: D

During the process of aging the systolic blood pressure often increases because of increasing stiffness of the blood vessels and increased vascular resistance. Increasing vagal tone may decrease the pulse rate.

TOP: Discipline: Pathophysiology MSC: Organ System: General a. 5 b. 10 c. 20 d. 25 e. 30

15. The difference in blood pressure readings between the right and left arms is considered normal up to _____ mm Hg.

ANS: B

Blood pressure readings between the left and right arms may vary by as much as 10 mm Hg and tends to be higher in the right arm.

TOP: Discipline: Physiology MSC: Organ System: Cardiovascular a. Blood pressure drop of more than 20 mm Hg in systolic and 10 mm Hg drop in diastolic b. Pulse rate decrease with a systolic pressure increase of at least 15 mm Hg c. Diastolic pressure increase of more than 5 mm Hg and no pulse rate changes d. Pulse rate decrease and diastolic pressure decrease of more than 5 mm Hg e. Decrease in pulse pressure

16. Postural hypotension is defined as which of the following when the patient stands compared with a sitting or supine reading?

ANS: A

Postural hypotension (orthostatic hypotension) represents a significant decrease in systolic pressure (greater than 20 mm Hg) and a 10 mm Hg drop in diastolic pressure as a patient changes from a sitting to a standing position. An increase in heart rate often occurs as well.

TOP: Discipline: Pathophysiology MSC: Organ System: Cardiovascular

17. The most frequent cause of serious hypertension in children is: a. malnutrition. b. liver failure. c. renal disease. d. rheumatic fever. e. heart disease.

ANS: C

Do not make the diagnosis of hypertension based on one reading. If the systolic blood pressure is elevated and the diastolic is not, anxiety may be responsible. Most children with a diagnosis of hypertension have an identifiable cause, usually renal disease.

TOP: Discipline: Pathophysiology MSC: Organ System: Cardiovascular

18. Systolic hypertension in the adult less than 60 years of age is generally defined as pressure in excess of: a. 120 + the patient s age. b. 140. c. 160. d. 180. e. 200.

ANS: B

Hypertension continues to be defined as a blood pressure consistently at 140/90 mm Hg or higher. The equation that s stolic blood pressure should be less than 120 + the patient s age is no longer the acceptable definition.

TOP: Discipline: Pathophysiology MSC: Organ System: Cardiovascular

19. The risk of hypertension in children is about four times higher for those with BMI (body mass index) more than: a. 50% b. 65% c. 75% d. 85% e. 95%

ANS: D

Because of the increase in numbers of children and adolescents who are obese, primary or essential hypertension is becoming more common. The risk of hypertension is about four times higher in children at more than 85th percentile of body mass index (BMI).

TOP: Discipline: Pathophysiology MSC: Organ System: Cardiovascular