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MODULE 3 NHA
Patient Intake and Vitals
| Question | Answer |
|---|---|
| Which of the following are the two most common identifiers used to confirm patient identity? A)Name and Social Security number B)Name and birth date C)Name and address D)Social Security number and birth date | B)Name and date of birth |
| A patient enters the medical office. The medical assistant greets them and verifies the patient’s name, address, telephone number, insurance information, and emergency contact. This specific information describes what is being verified? | Demographics |
| CHIEF COMPLAINT | Primary reason for the office visit. |
| SUBJECTIVE | Information gathered from what a patient communicates. Subjective information is usually described and experienced by the patient and is not measurable. |
| MEDICATION RECONCILITATION | Comparing the patient’s list of medications to the medical record as a safety measure to reduce the risk of improperly prescribing an incorrect or contraindicated prescription, including medication interactions and adverse reactions. |
| OBJECTIVE | Information that can be observed or measured. |
| What sections are inlcuded in the health record? | ADMIN., CLINICAL, ORDERS/REF, CLINICAL DATA, PROGRESS NOTES, DIAGNOSTIC IMAGINING INFO, LAB INFO MED LIST/ALLERGIES |
| A patient states they smoke two packs of cigarettes per day. This finding should be recorded in which of the following sections? A)Social history B)Past medical history C)Chief complaint D)Family history | A) SOCIAL HISTORY |
| Which of the following is objective information? A)Stomach pain B)Blood pressure 128/74 mm Hg C)Nausea D)Heart rate 88/min E)Weight 175 | B)BP 128/74 mm Hg D) Heart rate 88/min E)Weight 175 lb |
| Which of the following is an example of what the medical assistant may be responsible for documenting? A)Review of systems B)Medical history C)Family history D)Social history E)Chief complaint | B)Medical history C)Family history D)Social History E)Chief complaint |
| Patient Health Questionnaire-2 (PHQ-2) | focuses on the patient’s frequency of depressed mood over two weeks. |
| Patient Health Questionnaire-9 (PHQ-9) | screening asks additional questions to assess if the patient meets the criteria for a depressive disorder diagnosis. |
| GAD-7 questionnaire | for general anxiety and used to screen patients for anxiety |
| Common Depression Symptoms | Difficulty going to sleep, staying asleep, or getting up in the morning Profound sadness and fatigue Change in appetite Loss of energy |
| Common Anxiety Symptoms | Heightened ability to observe or make connections Difficulty focusing on details A sense of panic Irritability Feeling cold, sweaty Heart palpitations Shortness of breath |
| Which of the following is a common sign of depression? A)Feeling anxious or nervous B)Binge eating C)Profound sadness and fatigue D)Illogical thought patterns | C) Profound sadness and fatigue |
| BLOOD PRESSUE | Measures the force of the blood circulating through the arteries. |
| AUSCULATION | Listening with a stethoscope. |
| SYSTOLIC | Measurement of force while the heart is contracting; top number on a blood pressure reading. |
| DIASTOLIC | Measurement of force while the heart is relaxing; bottom number on a blood pressure reading. |
| ORTHOSTATIC HYPERTENTSION | A significant drop in blood pressure during positional changes, particularly when the patient is moving from lying down to sitting or from sitting to standing; also known as postural hypotension. |
| KOROTKOFF SOUNDS | Distinct sounds that are hear throughout the cardiac cylce. |
| What phase of the Korotkoff souncs are systolic and diastolic? | phase I (the first sound heard, systolic) and V (the final sound heard, diastolic) |
| What are reasons to not use a particular limb for blood pressure readings? | One-sided mastectomy: Use the arm on the side not impacted by the mastectomy. Bilateral mastectomy: Use leg. Lymphedema: Use leg. Dialysis fistula: Use arm that is not affected. |
| WHAT IS NORMAL BP RANGE? | Less than 120 mm Hg AND Less than 80 mm Hg |
| WHAT IS ELEVATED BP RANGE? | 120 to 129 mm Hg AND Less than 80 mm Hg |
| WHAT IS STAGE 1 HYPERTENSION? | 130 to 139 mm Hg OR 80 to 89 mm Hg |
| WHAT IS STAGE 2 HYPERTENSION | 140 mm Hg or higher OR 90 mm Hg or higher |
| WHAT IS CONSIDERED HYPERTENSION CRISIS | Higher than 180 mm Hg AND/OR Higher than 120 mm Hg |
| BP RANGE OLDER THAN 12 | SYSTOLIC 110 to 130 DIASTOLIC 65 TO 80 |
| BP RANGE 6 TO 12 YEARS | SYSTOLIC 100 TO 120 DIASTOLIC 60 TO 75 |
| BP RANGE 3 TO 6 YEARS | SYSTOLIC 95 TO 110 DIASTOLIC 60 TO 75 |
| BP RANGE 1 TO 3 YEARS | SYSTOLIC 90 TO 105 DIASTOLIC 55 TO 70 |
| RADIAL PULSE | located on the thumb side of the wrist, is the most common site for taking an adult pulse. |
| BRACHIAL PULSE | inside the upper arm, is the most common for measuring pulse in children and using to measure blood pressure. |
| CAROTID | located in the neck just below the jawbone, is most common for use in emergency procedures. |
| TEMPORAL ARTERY | located on the side of the forehead |
| FEMORAL ARTERY | located on the inner groin area |
| POPLITEAL ARTERY | located behind the knee |
| POSTERIOR TIBIAL ARTERY | located behind the ankle |
| DORSALIS PEDIS ARTERY | located on top of the foot |
| How it the apical pulse measured? | by listening with a stethoscope to the heartbeat at the apex of the heart. Measure for 1 full mimute |
| NORMAL Pulse range adolescent and older | 60 to 100 beats/min |
| NORMAL pulse school-age child (6 to 15 years) | 75-118 beats/min |
| NORMAL pulse toddler (1 to 2) | 98 to 140 beats/min |
| NORMAL pulse infant (1-12 months) | 100 to 180 beats/min |
| RESPIRATION | One complete inhalation and exhalation. |
| HYPERVENTILATION | Fast/Rapid breathing POSSIBLE CAUSES: Intense pain Anxiety Panic attacks |
| HYPERPNEA | Excessively deep breathing POSSIBLE CAUSES: Extreme pain or anxiety |
| DYSPNEA | Difficult or painful breathing POSSIBLE CAUSES: Chronic obstructive pulmonary disease (COPD) Pneumonia Asthma High altitudes Physical exertion |
| ORTHOPNEA | Difficulty breathing unless in the upright position POSSIBLE CAUSES: Congestive heart failure COPD |
| WHEEZING | Whistling sound during breathing POSSIBLE CAUSES: ASTHMA |
| RALES | Small clicking, bubbling, or rattling sounds POSSIBLE CAUSES: Small clicking, bubbling, or rattling sounds |
| RHONCHI | Large airway sounds POSSIBLE CAUSES: COPD Chronic bronchitis Pneumonia |
| NORMAL RESP RATE ADOLESCENT AND OLDER | 12 to 20 (breaths/min) |
| Normal resp. rate school age (6 to 15) | 18 to 25 (breaths/min) |
| Normal resp. rate preschooler (3 to 5) | 20 to 28 (breaths/min) |
| Normal resp. rate toddler (1 to 2) | 22 to 37 (breaths/min) |
| Normal resp. rate infant (1 to 12 months) | 30 to 53 (breaths/min) |
| What is normal Pulse Ox? | 95% or higher for example, noted as SpO2 98% |
| HYPOXEMIA | Decreased oxygen in the blood |
| PYREXIA | Fever greater then 100.4 F |
| How much lower is Axillary (Ax) temp than oral temp? | Aprox 1 F (0.6 C) |
| How much higher are tympanic, rectal and temporal artery temps than oral? | 1 F (0.6 C) |
| What is the normal temp for a newborn (axillary)? | 98.2 F |
| What is the normal temp for a 1 year old (tympanic)? | 99.7 F |
| What is the normal temp for 6 year to adult (oral)? | 98.6 F |
| What is the normal temp for adults over age 70 (oral)? | 96.8 |
| Which of the following Korotkoff phases is indicative of the diastolic recording? A)Phase I B)Phase II C)Phase III D)Phase IV E)Phase V | E) Phase V (all sounds disappear) |
| What can occur if the wrong size blood pressure cuff is used? | The systolic and diastolic can be impacted by up to 6.9 mm Hg. |
| Which of the following sites is most commonly used to check a pulse in children? A)Brachial B)Radial C)Carotid D)Temporal | A)Brachial |
| Which of the following are assessed when taking a pulse? A)Rate B)Depth C)Rhythm D)Strength | A)Rate C)Rythm D)Strength |
| APNEA | Priodic cessation of breathing |
| BRADYPNEA | Abnormaly slow breathing |
| TACHYPNEA | Rapid shallow breathing |
| DYSPNEA | Difficulty breathing |
| ORTHOPNEA | Difficulty breathing unless in upright position |
| Which of the following is the respiratory expected reference range for an adult? A)26 to 40/min B)20 to 30/min C)18 to 24/min D)12 to 20/min E)10 to 20/min | D) 12 to 20/min |
| While observing pulse oximetry, the MA notices the reading is 89%. What should the medical assistant do, and why? | Expert Response Notify the provider of the reading and await further instruction. |
| Which of the following does an oximeter measure? A)Oxygen saturation in the blood B)Oxygen saturation in the skin C)Electricity of the heart D)Blood pressure E)Heart rate | A)Oxygen saturation in the blood |
| What are somef actors that can affect a temperature reading? | Drinking hot or cold liquids, smoking, chewing gum, cold weather, hot weather, age, and menstrual cycle can affect a temperature reading. |
| Which of the following temperature sites does not have to be indicated when documenting the reading in the patient’s health record? A)Tympanic B)Oral C)Rectal D)Temporal artery | B) Oral |
| In addition to documenting the number for the pain level, which of the following characteristics of the patient’s pain need to be documented? A)Location B)Onset C)Duration D)Cause E)Characteristics | A)Location B)Onset C)Duration E)Characteristics |
| ANTHROPOMETRIC | Related to measurement and proportion of the body. |
| The circumference of a child’s head should be measured at a well-child visit until which of the following ages? A)1 year B)2 years C)3 years D)5 years | C) 3 years The brain has completed 75% of its growth by the time a child has reached 3 years of age. Therefore, it is recommended that head circumferences are only measured until the age of 3. |
| What is the formula to convert kilograms to pounds? | MULTIPLY the weight in pounds by 2.2. |
| What is the formula to convert pounds to kilograms? | DIVIDE the weight in pounds by 2.2 |
| BODY MASS INDEX (BMI) | An individual’s weight divided by the square of their height, used to determine weight status. BMI= height in m 2 weight in kg |
| A 30-year-old patient’s vital signs are temperature 98.2° F, heart rate 117/min, respirations 18/min, blood pressure 146/94 mm Hg. Which of the following vitals are outside the expected ref range? Temperature Heart rate Respirations Blood pressure | HEART RATE BLOOD PRESSURE |
| Which of the following are abnormal vital signs in an adult? A)Heart rate 88/min B)Respiratory rate 28/min C)Temperature 102° F D)Blood pressure 110/68 mm Hg | B)Respiratory rate 28/min C)Temperature 102° F |
| An adult patient has started taking medication for hypertension since their last visit. Which would the MA most likely expect at this visit? BP within normal range BP higher than normal BP lower than normal BP lower than it was on the previous visit | BP lower than it was on the previous visit |
Created by:
lizd3281