This Document Contains Chapters 3 to 5 Chapter 3 Question 1 Which of the following is true about the login you use for the Student Edition software? 1. It must be kept secret. 2. It creates a permanent record of your use of the software. 3. It is unique to you. 4. It serves as your electronic signature. Answer: 3 Rationale 1: The Student Edition software will use the student’s name or student ID as the login Rationale 2: The login in a healthcare facility will create a permanent record of the individual’s use of the system Rationale 3: The Student Edition login is unique to the student Rationale 4: The login and PIN in the healthcare facility EHR serves as the electronic signature of the user Question 2 In which section of the Student Edition software is the Hx tab located? 1. Encounter View Pane 2. Medcin Nomenclature Pane 3. Menu Bar 4. Entry Details Answer: 2 Rationale 1: The encounter view pane is the right pane of the window, and will display the encounter note as it is being created Rationale 2: The Medcin Nomenclature pane has eight tabs, including the Hx tab Rationale 3: The menu and tool bar are at the top of the screen, and include the words “select” “Enter” “options” “Forms” “Summary” “Graph” and “Help” Rationale 4: The entry details for the current finding are found at the bottom portion of the screen Question 3 Which of the following is not an example of a function menu in the Student Edition software? 1. Options 2. Graph 3. Encounter 4. Enter Answer: 3 Rationale 1: Options is a selection on the menu bar; clicking on the word will cause a list of functions to drop down below the word Rationale 2: Graph is a selection on the menu bar; clicking on the word will cause a list of functions to drop down below the work Rationale 3: The encounter view pane is the right pane of the window that displays the encounter note as it is being created Rationale 4: Enter is a selection on the menu bar; clicking on the word will cause a list of functions to drop down below the work Question 4 Where within the Student Edition software can you locate a finding associated with its appropriate ICD-9-CM code? 1. Entry Details 2. Note View 3. Sx tab 4. Outline View Answer: 4 Rationale 1: Entry details for a current finding are found on the bottom portion of the screen; entry of data in these fields adds informational text to the finding in the encounter note Rationale 2: Within the encounter view pane, free text may be entered and will appear in the Note View pane Rationale 3: Client reported symptoms are entered on the Sx tab Rationale 4: The Outline View, which is a tab found in the Encounter View Pane, displays findings that have been selected and appropriate ICD9-CM codes Question 5 When using the Student Edition software, what is the first step in every encounter once you have logged in? 1. Creating a new encounter 2. Selecting a Patient 3. Assigning a finding 4. Verifying client information Answer: 2 Rationale 1: A client must be selected prior to creating a new encounter Rationale 2: A client must be selected prior to creating a new encounter, or opening an existing encounter Rationale 3: A client must be selected prior to assigning a finding Rationale 4: A client must be selected prior to reviewing and verifying client information Question 6 The Sx tab on the Nomenclature pane is associated with which component of the SOAP format? 1. Subjective 2. Objective 3. Assessment 4. Plan Answer: 1 Rationale 1: The Sx tab, for symptoms, is where the client’s reported subjective information is documented Rationale 2: Objective information, such as that found during a Px, or physical examination Rationale 3: The assessment information is entered in the Dx tab, or diagnosis, syndromes, and conditions Rationale 4: The plan or therapy for the client is entered in the Rx tab Question 7 You are viewing findings in the Medcin Symptoms tab and notice that “facial twitching” has neither a small plus sign nor a small negative sign beside it. What does this mean? 1. This symptom is not the right match for the client. 2. Facial twitching is the main title for a new subcategory. 3. The tree for this finding has been collapsed. 4. This is the most specific finding available for symptom. Answer: 4 Rationale 1: The lack of a small plus sign or small negative sign does not indicate that it is an incorrect match for this client Rationale 2: The lack of a small plus sign or small negative sign does not indicate that facial twitching is the main title for a new category Rationale 3: The lack of a small plus sign or small negative sign does not indicate that the tree for this finding has been collapsed Rationale 4: The lack of a small plus sign or small negative sign indicates that it is the most specific finding available for this symptom Question 8 You are trying to locate the client Robert Smith in the Student Edition Patient Selection window. Which of the following would be the quickest way to locate his record? 1. Typing his patient identification number 2. Typing the client’s first name and last name 3. Scrolling through the list of client names 4. Entering the client’s last name, followed by R Answer: 4 Rationale 1: It will be time consuming to determine the client’s ID number Rationale 2: Typing the client’s first name and last name is not the appropriate way to locate the client Rationale 3: Scrolling through the client list is time consuming Rationale 4: Entering Smith, followed by R is the quickest way to locate this client’s record Question 9 What is the main purpose of an EHR system that is based on the Medcin nomenclature? 1. To document clinical notes in a codified electronic medical record 2. To allow providers to write prescriptions electronically 3. To perform drug utilization reviews and send alerts 4. To provide both clients and healthcare providers equal access to information Answer: 1 Rationale 1: Documenting clinical notes in a codified electronic record with Medcin allows care to be codified Rationale 2: CPOE function of an EHR system allows providers to write prescriptions electronically Rationale 3: The Medcin nomenclature is not responsible for DUR and alerts Rationale 4: The Medcin nomenclature is not related to connectivity Question 10 Which of the following statements is not true about an encounter note? 1. It often includes data that was entered by different healthcare professionals. 2. It is a record of the clinical findings from a client examination. 3. It reflects findings from an exam that occurred on a specific date. 4. It is a longitudinal record of the care a client has received. Answer: 4 Rationale 1: The encounter note has information that may be entered by several different healthcare professionals Rationale 2: The clinical findings from a client examination is entered in the Px tab of the client encounter Rationale 3: The encounter note is dated and timed Rationale 4: The encounter note is the record of a single encounter Question 11 Under what circumstances is a new encounter created for a client? 1. When a client introduces new symptoms during an office visit 2. When a provider orders blood work for a client as part of an annual physical exam 3. When a client calls a medical office with a billing inquiry 4. When a client visits her nurse practitioner with symptoms of the flu Answer: 4 Rationale 1: The encounter not would be edited if the client offers new symptoms during the same visit Rationale 2: The provider will order lab work using the Tx tab of the encounter note that is in progress Rationale 3: The billing professionals will note the inquiry within the billing software, not with a new encounter note Rationale 4: A new encounter is created when a professional in the office sees the client Question 12 A client tells you that he has been having back pain for over a month. Later in the exam, he remembers the pain seems to be getting worse. How would you record this finding information in the EHR? 1. Back-related symptoms 2. Back pain, episodes recently worse 3. Chronic/recurring, back pain 4. Back pain, chronic/recurring, episodes recently worse Answer: 4 Rationale 1: Entering “back related symptoms” is not specific enough for the encounter Rationale 2: “Back pain, episodes recently worse” is not specific enough Rationale 3: “Chronic recurring back pain” is not specific enough Rationale 4: “Back pain, chronic/recurring, episodes recently worse” utilizes the findings menu to the most specific level Question 13 All of the following Entry Details fields are stored in the EHR as fielded data except: 1. Modifier 2. Free text 3. Value 4. Episode Answer: 2 Rationale 1: A modifier is noted in the ICD-9 coded data field that will be searchable in the future Rationale 2: Free stored in the encounter note as non-codified data Rationale 3: A laboratory value is stored in a coded data field Rationale 4: Episode is a coded data field Question 14 Why is the first item in each drop-down list within the Entry details fields a blank? 1. To enable the user to search 2. To enter free text 3. To clear certain Entry Details fields 4. To modify a selected finding Answer: 3 Rationale 1: The first item in the drop-down list within the Entry details fields is not empty in order to allow the user to search Rationale 2: The first item in the drop-down list is not empty for the user to enter free text Rationale 3: The first item in the drop-down list is empty to clear the field; this ensures that inaccurate entries are not made Rationale 4: The first item in the drop-down list is not empty to allow for modification Question 15 Which of the following is not an advantage of the free-text entry window? 1. The window is large enough to allow a clinician to type a longer note. 2. The text entered in this window is stored as fielded data. 3. The clinician can use a spell checker to proofread her text. 4. It includes an insert text feature that helps save typing time. Answer: 2 Rationale 1: The free text window is large enough for the clinician to add a nuance to a finding that extends its meaning Rationale 2: The free text is not searchable, fielded data Rationale 3: The clinician can spell-check text entered in the free text window Rationale 4: The insert text feature allows frequently used text that has been stored to be inserted as free text whenever appropriate, saving time typing Question 16 Which of the following is the Medcin tab used for “tests performed”? 1. Sx 2. Rx 3. Tx 4. Dx Answer: 3 Rationale 1: Sx represents the client’s symptoms, or subjective data Rationale 2: Rx represents the plan of care or medications ordered Rationale 3: Tx represents tests ordered Rationale 4: Dx represents the diagnosis, syndromes and conditions Question 17 Which of the following is the Medcin tab for “treatments”? 1. Sx 2. Rx 3. Tx 4. Dx Answer: 2 Rationale 1: Sx represents the client’s symptoms Rationale 2: Rx represents therapy or plan Rationale 3: Tx represents tests Rationale 4: Dx represents diagnosis, syndromes, and conditions Question 18 Where are the Entry Details fields located in the Student Edition software? 1. In the right pane of the window 2. At the bottom portion of the screen 3. In the left pane of the window 4. Along the top portion of the screen Answer: 2 Rationale 1: The Encounter View pane is located in the right pane of the window Rationale 2: The Entry details fields are located at the bottom portion of the screen Rationale 3: The left pane of the window displays the lists of Medcin findings in the left pane of the window Rationale 4: The toolbar and menu bar are located at the top of the window Question 19 Where is the Note View tab within the main window of the Student Edition software located? 1. The Medcin Nomenclature Pane 2. The Encounter View Pane 3. The Menu Bar 4. Outline View Answer: 2 Rationale 1: The Medcin Nomenclature pane has 8 tabs, including “Sx” “Hx” “Px” “Tx” “Dx” “Rx” and “Edit” Rationale 2: The encounter view pane has two tabs, the Note View and Outline View Rationale 3: The Menu bar and Tool bare contains the following menus: Select, Enter, Options, Forms, Summary, Graph, and Help Rationale 4: The Outline View is found within the Encounter View Pane, and displays findings that have be selected and appropriate ICD9-CM codes Question 20 If you are entering information about tests that have been performed on a client, you are most likely to select which tab in the Nomenclature Pane? 1. Sx 2. Px 3. Tx 4. Rx Answer: 3 Rationale 1: The Sx tab is used to document the client’s reported symptoms Rationale 2: The Px tab is used to report the findings from the physical examination Rationale 3: The Tx tab is used to report the tests that are being ordered Rationale 4: The Rx tab is used to identify the therapy, such as medication, or treatment plan Question 21 The following steps are followed when signing in to the Medcin Student Edition software: Standard Text: Select all that apply. 1. Enter name or student ID 2. Enter social security number for identification 3. Double click on the Medcin icon 4. Click the cancel button 5. Click on Select Answer: 1, 3 Rationale 1: The student must first enter the name or student ID Rationale 2: The social security number is not used for identification in the Medcin Software Rationale 3: The Medcin icon is double clicked to display the Student Edition login screen Rationale 4: The cancel button is not used to sign it; it is used to stop the sign in process Rationale 5: The Select tab is not used to open the Medcin Software Question 22 The nurse is preparing to enter a client encounter. The first step in every encounter is to Select: 1. New Encounter from the Select menu 2. Client from the select menu 3. Existing Encounter from the Select menu 4. Enter from the Menu bar Answer: 2 Rationale 1: New encounter is not the first step Rationale 2: The first step in every encounter is to select the client Rationale 3: The first step in a new encounter is not selecting an existing encounter Rationale 4: The first step in every encounter is not selecting Enter from the menu bar Question 23 The nurse is caring for a client who has been to the office several times for a recurring UTI. The appropriate action when beginning the office visit is to: 1. Edit an existing encounter to enter follow-up information 2. Create a new encounter 3. Order a new urinalysis 4. Review test results Answer: 2 Rationale 1: The appropriate action is not editing an existing encounter Rationale 2: The appropriate action is to create a new encounter Rationale 3: The first step is to create a new encounter Rationale 4: Reviewing test results is done after creating a new encounter Question 24 The nurse has checked the client’s vital signs, and performed an EKG. This information would be documented using which tab? 1. Sx 2. Tx 3. Rx 4. Dx Answer: 2 Rationale 1: The client’s symptoms or subjective information is documented in the Sx tab Rationale 2: Tests that are performed in the current encounter, which is objective information, is documented in the Tx tab Rationale 3: Tests that are ordered for the future are entered in the Rx tab Rationale 4: The diagnosis is entered in the Dx tab Question 25 The client reports pain in the left leg. During the course of the encounter, the client states “I am so confused. It is my right leg.” The appropriate action for the nurse to take is: 1. Delete the encounter 2. Create a new encounter 3. Edit the existing encounter 4. Sign out without saving the information and start over Answer: 2 Rationale 1: Deleting the encounter is not the appropriate nursing action Rationale 2: Creating a new encounter is not the appropriate nursing action Rationale 3: Editing the existing encounter by removing ‘in the left leg’ from the current encounter note and adding “in the right leg” Rationale 4: Signing out without saving the encounter is not the appropriate action Question 26 The client has been seen several times for a recurring UTI, having been treated for three weeks without relief. Appropriate documentation in the Sx field includes: Standard Text: Select all that apply. 1. Adding a status comment 2. Adding a free text comment 3. Adding a diagnosis 4. Adding to the nursing care plan 5. Editing a previous encounter Answer: 1, 2 Rationale 1: Adding a status comment such as “failing to change as expected” improves the accuracy of the encounter note Rationale 2: Adding a free text comment such as “symptoms keeping her awake” improves the accuracy of the encounter note Rationale 3: Adding a diagnosis would not be done in the Sx tab Rationale 4: Adding to the nursing care plan would not be done in the Sx tab Rationale 5: Editing a previous encounter is not an appropriate action Question 27 The nurse is recording a client’s height and weight. The appropriate tab to click is the: 1. Select 2. Encounter 3. Forms 4. Nursing Answer: 3 Rationale 1: Select is the appropriate tab to click when selecting the client Rationale 2: Encounter is not the appropriate tab to click to enter height and weight Rationale 3: The forms tab on the bottom left corner is to appropriate tab to click to navigate towards the Vitals menu Rationale 4: The Nursing tab is not the appropriate tab to click to access the Vitals menu Question 28 The nurse is preparing to enter the client’s chief complaint of burning on urination. The appropriate actions to take include: Standard Text: Select all that apply. 1. Locate the button on the Toolbar labeled ROS 2. Locate the button on the Toolbar labeled Chief 3. Enter text in the chief Complaint window 4. Click the mouse on Enter to record the note 5. Select the appropriate Chief complaint from a list Answer: 2, 3 Rationale 1: The ROS button stands for review of symptoms Rationale 2: The Chief button opens the Chief complaint window Rationale 3: Once the Chief complaint window is open, the Chief Complaint text is entered: Burning with urination continues since last visit Rationale 4: The appropriate button to click to enter the Chief complaint is “Close the note form” Rationale 5: Opening the Chief complaint window does not invoke a menu list Question 29 Nursing care is entered in the: 1. Rx tab 2. Forms view 3. Px tab 4. Nursing tab Answer: 1 Rationale 1: Rx (therapy) is the appropriate tab to click to enter applicable nursing care Rationale 2: The Forms view is not the appropriate tab to click to enter Nursing care Rationale 3: Px is the appropriate tab to click for entering physical examination findings Rationale 4: The Nursing tab is not the appropriate tab for entering nursing care Question 30 The nurse is reviewing a free text entry describing a test that is scheduled for a client. The advantages to using a free text entry instead of a Status entry include: Standard Text: Select all that apply. 1. Free text is easier 2. Free text is stored as fielded data 3. Status adds informational text to the finding 4. Status is stored as fielded data 5. A status entry is a better choice Answer: 3, 4, 5 Rationale 1: Free text is actually more difficult to enter Rationale 2: Free text is not stored as fielded data Rationale 3: Status adds informational text, such as “client scheduled for” to describe an upcoming test Rationale 4: Information in a status entry is stored as fielded data Rationale 5: The status entry has many advantages over the Free text entry Chapter 4 Question 1 Which of the following should be typed in the field of the log in screen for the Student Edition software? 1. Your course code 2. Your school’s name 3. Your name or student ID 4. Your e-mail address Answer: 3 Rationale 1: The course code will not open the Student Edition software Rationale 2: The school name will not open the Student Edition software Rationale 3: The student name or ID will open the Student Edition software Rationale 4: The email address will not open the Student Edition software Question 2 You want to start the Student Edition software but do not see the Medcin icon. What should you do? 1. Reboot your computer, and then try opening the software again. 2. Check to make sure your screen is maximized. 3. Hit Exit on the Menu bar to close the software, and then retry opening it. 4. Click on the Start button, and then look in Programs to find it. Answer: 4 Rationale 1: Rebooting the computer is not the first action in this situation Rationale 2: Having the screen maximized is not the appropriate action in this situation Rationale 3: If you are unable to see the Medcin icon, then the software is not open, and closing it is not the appropriate action at this time Rationale 4: Clicking on the Start button, and looking in Programs or All programs for the program named “Medcin Student Edition” is the appropriate action Question 3 You are creating a new encounter for the client Davida Johnson. At what point do you select “New Encounter” for this client when using the Student Edition software? 1. After you have located and clicked on the client’s name in the Patient Selection window. 2. Not until the physician has entered a diagnosis for the client. 3. After you have set the date and time for the New Encounter. 4. While you are setting up the appointment for the client. Answer: 1 Rationale 1: You must select the client’s name prior to entering a new encounter Rationale 2: The client name must be selected prior to the physician entering a diagnosis Rationale 3: The client’s name must be selected prior to setting the date or time Rationale 4: You cannot set up an appointment without knowing the client’s name Question 4 “Annual checkup” would be an example of a(n): 1. Alert 2. Reason for the encounter 3. Client symptom 4. Treatment plan Answer: 2 Rationale 1: An alert is generated by medication review or screening or prevention parameters Rationale 2: Annual checkup is an example of a chief complaint or reason for the encounter Rationale 3: A client symptom is a something that a client reports as troublesome that is not measurable by the nurse, such as pain or itching Rationale 4: A treatment plan is more detailed than “annual checkup” Question 5 When creating a new encounter using the Student Edition software, where do you enter the chief complaint? 1. Sx tab 2. Vital signs form 3. Note view 4. Dx tab Answer: 3 Rationale 1: The Sx tab is used to select subjective information reported by the client Rationale 2: The Vital signs form is used to enter blood pressure, pulse, temperature, height, and weight Rationale 3: The note view is used to enter the client’s specific complaint, such as “pain in leg, especially at night” Rationale 4: Applying Question 6 A client tells you that the medication he’s been taking to control his allergies is not working well. Which Entry Details field would you record this information? 1. Episode field of Entry Details 2. Duration field of Entry Details 3. Status field of Entry Details 4. Onset field of Entry Details Answer: 3 Rationale 1: The episode field allows a numeric entry Rationale 2: The duration field allows further detail regarding frequency or intervals to be entered regarding a symptom Rationale 3: The status field of entry details allows further detail regarding efficacy of current treatment Rationale 4: The onset field allows further detail to be entered in the encounter note regarding a diagnosis Question 7 Under what tab in the Student Edition software would you expect to find “Benign syndromes”? 1. Dx 2. Sx 3. Rx 4. Tx Answer: 1 Rationale 1: The Dx tab allows the provider to choose from a list of diagnoses Rationale 2: The Sx tab allows the provider to choose from a list of symptoms that the client may be reporting Rationale 3: The Rx tab allows the provider to document current therapies, medications and nursing care orders Rationale 4: The Tx tab will display categories of tests that can be ordered Question 8 You have entered information about a client’s vital signs using the vital signs form. Where will this information appear on the encounter note? 1. Assessment 2. History of present illness 3. Physical findings 4. Chief complaint Answer: 3 Rationale 1: The assessment in the note view is the same as the diagnosis Rationale 2: The history of present illness is documented using selections from the Hx tab Rationale 3: Physical findings are measurements entered in the vitals form Rationale 4: Knowing Question 9 Within which tab would you expect to locate the finding “Examination of Scalp?” 1. Px 2. Sx 3. Rx 4. Tx Answer: 1 Rationale 1: Px is the tab used to select and enter physical examination findings Rationale 2: Sx is the tab used to select and enter client reported symptoms Rationale 3: Rx is the tab selected to select and enter therapy, nursing orders, etc. Rationale 4: Tx is the tab used to select and enter tests Question 10 A client provides a lengthy description of how her new restricted diet is helping to control her diabetes. You would use which of the following to record this information most effectively? 1. Result field within Entry Details 2. Finding Note window 3. Free-text field within Entry Details 4. Status field in the Px tab Answer: 2 Rationale 1: The result field is used to document results of a specific test or examination, such as a vision screening Rationale 2: The finding note window allows for more complete entry details Rationale 3: The Free-text field is limited in space Rationale 4: The status field in the Px tab is used to describe the efficacy of a therapy Question 11 Which of the following would not be an example of a social history finding within the Student Edition software? 1. Tobacco use 2. Trouble coping with change 3. Daily alcohol consumption was 1, 6oz. drink per day 4. Drug allergies Answer: 4 Rationale 1: Social history includes behaviors the client may engage in, including use of tobacco Rationale 2: Social history includes the client’s ability to cope with change Rationale 3: Social history includes behaviors the client may engage in, including alcohol consumption Rationale 4: Drug allergies would be noted in past medical history Question 12 When you have finished an exercise using the Student Edition software, you 1. do not need to save it because the software saves it automatically. 2. need to output your work to a printer or file, unless instructed otherwise. 3. should always print a hard copy of each exercise. 4. will export your file to a Word document, and then e-mail it to your instructor. Answer: 2 Rationale 1: The software does not automatically save entries in the Student Edition software Rationale 2: The student needs to print the work to a printer or file, or the work will be lost Rationale 3: The student does not always need to print a hard copy of each exercise Rationale 4: The student may output the work to a printer or files; or send to the instructor if instructed Question 13 Which of the following statements about a printed encounter note for a client is correct? 1. The Chief complaint and the Assessment contain the same information. 2. Sections on the form without any information appear blank. 3. The History of present illness section contains information on symptoms 4. The client must review the encounter note before the physician signs it. Answer: 3 Rationale 1: The chief complaint includes the client’s reported symptoms, while the assessment includes results of the physical examination and measurements Rationale 2: Sections on the for without any information are omitted Rationale 3: The history of present illness contains information reported by the client; symptoms Rationale 4: The encounter note does not have to be reviewed by the client; it is the physician’s record Question 14 Within which tab would you set a client’s cognitive functions to abnormal? 1. Rx tab 2. Px tab 3. Sx tab 4. Dx tab Answer: 2 Rationale 1: The Rx tab is used to select therapy options for the client’s care Rationale 2: The Px tab is used to record findings from the physical exam; further detail would be added using the “results” field Rationale 3: The Sx tab is used to select and record client reported symptoms Rationale 4: The Dx tab is used to select medical and nursing diagnoses Question 15 When printing or exporting encounter notes using the Student Edition software, remember that you: 1. can only print or export your work at the completion of an exercise. 2. need to use the Print icon on the computer. 3. will require access to a network printer or the Internet. 4. should have your printed note or exported file in hand before exiting. Answer: 4 Rationale 1: The student work can be printed at any time, but will not be complete Rationale 2: The student work needs to be printed using the Print button on the Medcin Student Edition screen Rationale 3: Printing an encounter can be done to a local printer Rationale 4: The student should be certain to have the printed not in hand prior to closing the software, otherwise the completed exercise will be lost Question 16 The past medical history for a client would most likely include which of the following details? 1. Current blood pressure 2. Insurance coverage 3. Age at time of exam 4. Previous surgeries Answer: 4 Rationale 1: Current blood pressure would be included in physical findings Rationale 2: Insurance information would be included in demographic information Rationale 3: The client’s age at exam is included in the history of present illness Rationale 4: Past medical and surgical history will include previous diagnoses, illnesses, injuries and surgeries Question 17 The nurse observes local swelling in a client’s leg. How would this finding be indicated in the Px tab of the Student Edition? 1. (Blue button) Lower extremity 2. (Red button) Localized 3. (Red button) Edema 4. (Blue button) Leg pain Answer: 3 Rationale 1: The blue button would indicate no swelling in the leg Rationale 2: Localized would indicate a small area of swelling, rather than the leg Rationale 3: The red button at edema indicates a current finding Rationale 4: The blue button at leg pain would indicate no leg pain Question 18 A nurse practitioner diagnoses a client with a rhinitis and prescribes fluids and rest. To locate this assessment in the Dx tab, where would you begin? 1. Nose 2. ENT Disorders 3. Instructions for Client 4. Rhinitis Answer: 2 Rationale 1: Diagnoses are grouped systematically, starting generalized to more specific Rationale 2: Diagnoses are grouped systematically, with ENT being the ear/nose/throat area of assessment Rationale 3: Instructions for the client would be located in the Rx tab Rationale 4: Rhinitis is the most detailed level for this diagnosis and required scrolling from general to specific Question 19 Under which tab is the client’s plan for therapy and treatment recorded? 1. Rx tab 2. Px tab 3. Sx tab 4. Dx tab Answer: 1 Rationale 1: The Rx tab is used to select and document therapy and treatment options Rationale 2: The Px tab is used to select and document physical exam findings Rationale 3: The Sx tab is used to select and document the client’s reported symptoms Rationale 4: The Dx tab is use to select and document the clients medical and nursing diagnoses Question 20 A client who has been in a minor car accident does not show any signs of a lower back injury. Where would you enter this information in the Student Edition software? 1. Rx tab 2. Px tab 3. Sx tab 4. Dx tab Answer: 2 Rationale 1: The Rx tab is used to select and document treatment and therapy options Rationale 2: The Px tab is used to select and document physical examination findings Rationale 3: The Sx tab is used to select and document the client’s symptoms Rationale 4: The Dx tab is used to select and document medical and nursing diagnoses Question 21 Which steps are necessary to login to the Student Edition software? Standard Text: Select all that apply. 1. Start the Student Edition software 2. Locate the Start icon on the desktop 3. Locate the Medcin icon on the desktop 4. Login using the student name 5. Select a patient Answer: 1, 3, 4 Rationale 1: The Student Edition software needs to be opened to enable login Rationale 2: The Start button is not an initial necessary step Rationale 3: Clicking on the Medcin icon will open the Student Edition login screen Rationale 4: The student name or ID may be used to login Rationale 5: The client name is not selected until after login is complete Question 22 The selection of the correct client is accomplished by: Standard Text: Select all that apply. 1. Click the word “Enter” 2. Click the word “Select” 3. Scroll to the appropriate client 4. Click the word “Browse” 5. Click the word “Details” Answer: 2, 3 Rationale 1: The word enter will not display a client list Rationale 2: The word “Select” will display a client list Rationale 3: Scrolling to the appropriate client, and clicking on the name will select a client for this encounter Rationale 4: The word “Browse” will not display a client list Rationale 5: The word “Details” will not display a client list Question 23 The appropriate option to click when preparing to enter a client’s vital signs is: 1. Encounter 2. Forms 3. Nursing 4. Enter Answer: 2 Rationale 1: The use of the encounter tab will not open the vital sign screen Rationale 2: The use of the Forms option on the toolbar or the Forms tab at the bottom of the screen will display the vital signs screen Rationale 3: The use of the Nursing tab will not display the vital signs screen Rationale 4: The use of the Enter option on the toolbar will not display the vital signs screen Question 24 The client is being admitted to the Emergency Department. The nurse takes the following steps to document the encounter: Standard Text: Select all that apply. 1. Click Enter on the Medcin Student edition toolbar 2. Click Select on the Medcin Student edition toolbar 3. Click Client on the Enter menu 4. Type the client’s last name, first name in the Client Selection window field 5. Select Emergency Department from the New Encounter menu list Answer: 2, 4, 5 Rationale 1: Clicking “Enter” on the toolbar will not open the client list Rationale 2: Clicking Select on the toolbar will open options including Client Rationale 3: Clicking on Patient from the Select menu will open the client list Rationale 4: Typing the client’s last name, first name will narrow the options in the client list Rationale 5: By clicking Select on the menu bar, then New Encounter will open a drop-down list with reasons for the new encounter Question 25 The nurse has opened the New Encounter for a client in the Emergency Department. The appropriate next step is to: 1. Enter the nursing diagnosis by locating the nursing tab 2. Entering the vital signs by locating the Forms tab 3. Enter the Chief complaint by locating the toolbar button labeled “Chief” 4. Clicking on the Dx tab Answer: 3 Rationale 1: The nursing diagnosis is not entered prior to the assessment Rationale 2: The Vital signs are not entered until the client history is documented Rationale 3: The Chief complaint is entered by clicking Chief on the tool bar, which opens a text dialog window Rationale 4: The Dx tab is used to enter diagnoses after the assessment is complete Question 26 When documenting the client’s symptoms, the general rule regarding the “red” or “blue” buttons is: 1. Red is used for lack of symptom 2. Red is used for history of a symptom 3. Blue is used for history of a symptom 4. Blue is used for a current symptom Answer: 2 Rationale 1: Blue is used to indicate a lack of a finding, such as no pain Rationale 2: Red is used after blue to document a history of a finding Rationale 3: Blue is used to indicate a lack of a finding Rationale 4: Red is used for a current finding Question 27 The use of the note form is indicated 1. If the nurse cannot find a diagnosis 2. If the nurse cannot find a symptom 3. If the nurse needs to expand on the detail of a selection 4. If the computer system is not functioning well Answer: 3 Rationale 1: The nurse will use the Dx tab to find a diagnosis Rationale 2: The nurse will use the Sx tab to find a symptom Rationale 3: The nurse will use the Note Form to expand on the detail of a finding Rationale 4: The nurse will not use the Note Form in the case of a system malfunction Question 28 In order to document a 12-year history of dysmenorrhea, the nurse will: 1. Select dysmenorrhea > Hx > Duration: 12 years > Prefix: History of 2. Select dysmenorrhea > Note form: for 12 years 3. Select dysmenorrhea 4. Select Note form: History of dysmenorrhea for 12 years Answer: 1 Rationale 1: Select dysmenorrhea > Hx > Duration: 12 years > Prefix: History of will yield codified data Rationale 2: Select dysmenorrhea > Note form: for 12 years will yield a current diagnosis of dysmenorrhea Rationale 3: Select dysmenorrhea will yield a present assessment of dysmenorrhea Rationale 4: Select Note form will yield uncodified data Question 29 The student has been assigned to save an encounter to a PDF files. The appropriate actions include: Standard Text: Select all that apply. 1. Click the Print button from the Start menu 2. Click the Print button on the Medcin toolbar 3. Click to clear the check mark on “Current Encounter” 4. Click on the button labeled “Export to XPS File” 5. Click on the button labeled “Export to PDF File” Answer: 2, 5 Rationale 1: Using the Print option from the start button will not control the Medcin software Rationale 2: The print button on the Medcin toolbar will open a print dialogue box specific to the current work Rationale 3: The Current Encounter box should be checked to print the current work Rationale 4: Export to XPS file will not save the document as a PDF file Rationale 5: Export to PDF File will save the document as a PDF file Question 30 The instructor has determined that the student work should be saved as a file that can be viewed with Adobe Acrobat Reader. On the Print dialog window, the student will select: 1. Printer Setup 2. Export to XPS File 3. Export to PDF File 4. Print and close Answer: 3 Rationale 1: Printer Setup will open a window for choosing paper and ink options Rationale 2: Export to XPS File will save the file as a Microsoft file that can be viewed with Internet Explorer Rationale 3: Export to PDF File will save as a file that can be viewed with Adobe Acrobat Reader Chapter 5 Question 1 Which of the following is not a characteristic of a Form? 1. It typically lists all findings by category. 2. It presents findings in the same place each time. 3. It includes check boxes to speed data entry. 4. It controls which findings are required and which are optional. Answer: 1 Rationale 1: A list is typically organized by category Rationale 2: A form presents findings in the same place each time to speed data entry Rationale 3: Check boxes are included to speed data entry Rationale 4: The form will not close if a finding (such as diastolic) is required Question 2 Which of the following is not true of an EHR system when used in a medical clinic? 1. It may take some time for healthcare providers to learn how to use the system. 2. It makes the nurse’s interaction with the client less personal. 3. It reduces the amount of paperwork to be done at the end of the day. 4. When used correctly it ensures that the client’s chart is always up-to-date. Answer: 2 Rationale 1: The learning curve may be steep during initial implementation of an EHR system Rationale 2: Once the nurse is familiar with the EHR system, more time will be spent with the client than with documentation Rationale 3: Point of use documentation reduces paper work at the end of the day Rationale 4: Point of use documentation ensures that the client’s chart is always up to date Question 3 Why are the Lists and Forms features in an EHR system useful to the nurse when seeing a client? 1. Because they speed up the billing and reimbursement process 2. Because they allow the client to independently select her symptoms 3. Because they help a clinician quickly locate evidence to support a diagnosis 4. Because they present the most frequently used findings in one place Answer: 4 Rationale 1: The lists and forms features is useful in the documentation of care Rationale 2: The provider enters the client symptoms Rationale 3: Lists and forms are used for data entry, not diagnosis support Rationale 4: Lists and forms present frequently used findings in one place and speed data entry Question 4 Which of the following is not true about a List in an EHR system? 1. To work efficiently, lists are limited to a single condition. 2. Lists are initially created manually by someone within a facility or practice. 3. A short list will require the clinician to scroll through fewer findings than a longer list. 4. Lists are typically created for the most commonly seen conditions. Answer: 1 Rationale 1: Lists are usually not limited to a single condition, but a group of conditions that are frequently used in the practice Rationale 2: The list is initially created manually Rationale 3: The short list will speed data entry Rationale 4: Lists are typically created and used for a group of conditions that are frequently encountered by the health care team using the EHR system Question 5 The nurse works in a pediatrician’s office that is implementing an EHR system. Which of the following conditions is least likely to warrant the creation of a List? 1. Otitis media 2. Influenza 3. Degenerative joint disease 4. Acne Answer: 3 Rationale 1: Otitis media is a common diagnosis encountered in pediatric clients Rationale 2: Influenza is a common diagnosis encountered in pediatric clients Rationale 3: Degenerative joint disease in not encountered frequently in pediatric clients Rationale 4: Acne is a common diagnosis encountered by the adolescent client of a pediatrician Question 6 When using a specific list in the Student Edition software, what would you expect to see in the left pane of the Sx tab display? 1. The full Medcin Nomenclature 2. A past medical history for the client 3. Symptoms related to the client’s chief complaint 4. A form with symptoms listed by body system Answer: 3 Rationale 1: The full Medcin nomenclature is not displayed when using a list Rationale 2: The past medical history would be located in the Hx tab Rationale 3: The Sx tab display will show symptoms related to the chief complaint Rationale 4: The Sx tab will not display a form while a list is in use Question 7 The attending physician has diagnosed a client with a hyperthyroidism. This nurse understands that this diagnosis relates to which of the following body systems? 1. Cardiovascular 2. Endocrine 3. Gastrointestinal 4. Genitourinary Answer: 2 Rationale 1: The thyroid gland is not part of the cardiovascular system Rationale 2: The thyroid gland is part of the endocrine system Rationale 3: The thyroid gland is not part of the gastrointestinal system Rationale 4: The thyroid gland is not part of the genitourinary system Question 8 Mr. Talbot visits the clinic with a suspected sinus condition. Which of the following statements is true? 1. The nurse will document the symptoms that correspond to his final diagnosis. 2. The nurse will use the ROS to document symptoms directly related to the chief complaint. 3. The nurse will interview Mr. Talbot and enter all of his symptoms in the HPI. 4. The nurse will document symptoms related to Mr. Talbot’s present illness within the HPI. Answer: 4 Rationale 1: The nurse will document all of the client’s symptoms Rationale 2: Typically ROS is used in addition to the HPI to document findings related to the HPI Rationale 3: The nurse will document symptoms related to the present illness in the HPI Rationale 4: The nurse will document symptoms related to the present illness in the HPI Question 9 When using the Student Edition software, how do you know that the ROS groupings in “on”? 1. The ROS button is blue. 2. The ROS button is orange. 3. The ROS button is gray. 4. The ROS button does not change. Answer: 2 Rationale 1: The ROS button will be orange when it is active, and blue when inactive Rationale 2: The ROS button will be orange when it is active and blue when inactive Rationale 3: The ROS button is not gray Rationale 4: The ROS button changes color when active or inactive Question 10 When using the Student Edition software, where do the symptoms you select when the ROS button is activated appear on the printed encounter note? 1. Review of systems 2. Vital signs 3. Assessment 4. Allergies Answer: 1 Rationale 1: The symptoms entered using the ROS button appear in the Review of Systems area of the encounter note Rationale 2: The vital signs appear under physical findings in the encounter note Rationale 3: The assessment appears under ROS in the encounter note Rationale 4: Allergies appear under the ROS or Assessment Question 11 Which of the following is not true about the ROS button on the Toolbar? 1. When the button is on, it applies to all the symptoms selected. 2. It is available anytime you are on the Sx tab. 3. It records symptoms on the Review of Systems portion of the encounter. 4. When the button is on, it only affects a selected finding. Answer: 4 Rationale 1: When the ROS button is on, the symptoms selected are recorded in the Review of Systems section Rationale 2: The ROS button is available anytime symptoms (Sx) are being entered Rationale 3: When the nurse activates the ROS button on the toolbar, it records symptoms on the ROS portion of the encounter note Rationale 4: When the ROS button is on, it affects all symptoms selected Question 12 On which of the following tabs will the Auto Negative button function? 1. Sx and Dx 2. Hx and Rx 3. Px and Sx 4. Tx and Rx Answer: 3 Rationale 1: The Auto Negative button works on the Sx tab, but the Diagnosis will never be negative Rationale 2: The Auto Negative button is not operational for the history or therapy buttons Rationale 3: The Auto Negative button speeds documentation by selecting ‘normal’ the finding for any assessment area not otherwise noted in Px (physical exam) and Sx (symptoms) Rationale 4: The Auto Negative button speeds documentation by selecting ‘normal’ the finding for any assessment area not otherwise noted in Px (physical exam) and Sx (symptoms) Question 13 You have selected the Auto Negative button to record a client’s symptoms. This feature will: 1. automatically record all of the body system categories in the ROS as normal. 2. record all previously unselected symptoms related to the client’s condition as normal. 3. search the symptoms that have been selected by the nurse and make sure they match the HPI. 4. record the symptoms the client has reported. Answer: 2 Rationale 1: The Auto Negative button does not automatically record all symptoms as negative in a ROS Rationale 2: The Auto Negative button automatically records al previously unselected symptoms as normal Rationale 3: The Auto Negative button does not check the symptoms Rationale 4: The Auto negative button does not record all the symptoms the client has reported; the nurse selects the appropriate symptoms Question 14 When using a list for a specific condition in an EHR, the Rx tab is least likely to display which of the following? 1. An experimental treatment 2. A generic drug equivalent 3. An over-the-counter drug 4. A brand name drug Answer: 1 Rationale 1: Experimental treatments change frequently, and would not be an appropriate item to include on a list Rationale 2: A generic drug equivalent of a commonly used medication may be included on a list for ease of documentation Rationale 3: An over-the-counter drug that is used frequently may be included on a list for ease of documentation Rationale 4: A brand name drug often prescribed for a frequently encountered condition may be included on a list for ease of documentation Question 15 A client indicates that he is currently taking no medications other than multivitamins. Where would this information be recorded on the printed encounter note? 1. Physical findings 2. Past medical/surgical history 3. History of present illness 4. Behavioral history Answer: 2 Rationale 1: Physical findings include current physical exam findings Rationale 2: Past medical/surgical history includes current medications Rationale 3: HPI includes current symptoms Rationale 4: Behavioral history includes substance use or other client behaviors Question 16 Which of the following is not true about check boxes when they appear in a form within an EHR? 1. All boxes that are checked will appear on the client’s record. 2. Once a box has been checked, it is difficult to deselect. 3. To record a finding, the user clicks on a box to create a check mark. 4. A check placed within a N box indicates a client does not have something. Answer: 2 Rationale 1: The check boxes in a form indicate that the selection will appear on the client’s record Rationale 2: Checked boxes are easily deselected Rationale 3: To select a finding, the nurse will click on the box to create a check mark Rationale 4: A check placed in a Y box indicates the client has something; a check in the N box indicates the client does not have something Question 17 Your client only reports a few symptoms during an examination. Which of the following would be the fastest way to complete Form pages for this client encounter? 1. Place a check mark in all of the N boxes. 2. Skip all options that do not apply to the client’s HPI. 3. Use free text to type a note: Client is generally healthy, with few symptoms. 4. Click on the “Negs” button in the Toolbar. Answer: 4 Rationale 1: Check marks must be entered individually Rationale 2: A for requires a y or n entry Rationale 3: Free text is not available in a Form Rationale 4: The Negs button will automatically record the normal lack of symptoms Question 18 The nurse is using a form to record information in the Student Edition software, but wants to make sure everything has been captured. The quickest option would be to: 1. switch to the Encounter tab to verify all the information is correct. 2. print the encounter note and proofread it before continuing. 3. select Outline View to see all of the findings you have currently selected. 4. choose Note View to see the encounter form in its current form. Answer: 3 Rationale 1: The Encounter tab is not the quickest option Rationale 2: Printing the note is not the quickest option Rationale 3: The Outline view will display a form with Y and N options Rationale 4: The Note View is not the quickest option Question 19 Which of the following statements is not true about the Auto Negative feature in the Student Edition software? 1. It may be considered an “auto normal” feature. 2. It saves providers time when they are using both Lists and forms. 3. It automatically uses N when it populates check boxes. 4. It does not automatically override the findings the user has already selected. Answer: 3 Rationale 1: The Auto Negative feature, when active, automatically populates the normal findings of a selection Rationale 2: The Auto Negative feature may be used in both Lists and Forms, and speeds documentation Rationale 3: The Auto Negative feature does not automatically use Y or N Rationale 4: The Auto Negative does not alter findings that are already recorded Question 20 A nurse records an inpatient’s admission diagnosis using which of the following? 1. Sx tab and HPI button. 2. Hx tab and ROS button. 3. Dx tab and Prefix field. 4. Px tab and Status field. Answer: 3 Rationale 1: The nurse uses the Sx tab and HPI button to record the client’s reported symptoms Rationale 2: The Hx tab and ROS button are used to enter past medical history and present findings Rationale 3: The Dx tab and the Prefix field are used to document the assessment (diagnosis) for the client being admitted to a facility Question 21 The use of lists and forms at point of care documentation enables the nurse to: Standard Text: Select all that apply. 1. Record data quickly 2. Clarify the any point of concern 3. Wait until the end of the shift to chart 4. Accurately document symptoms, history, etc. 5. Make client data available to other caregivers immediately Answer: 1, 2, 4, 5 Rationale 1: The use of Lists and Forms Speeds data entry Rationale 2: The use of point of care documentation enables the nurse to ask the client to elaborate or clarify any point of concern Rationale 3: The nurse who documents at point of care is done with the documentation required for that encounter Rationale 4: The use of lists and forms at point of care enables the nurse to document accurately in real time Rationale 5: Documenting at point of care enables other caregivers to immediately access the client health information Question 22 The acute care facility may create lists for which of the following reasons: Standard Text: Select all that apply. 1. Geographic location may cause a facility to see more cases of a particular nature than similar facilities in another region 2. There may be seasonal increases of certain diseases 3. The facility may focus on certain diseases 4. The facility wants the caregivers to spend more time carefully documenting 5. The physician may specialize in certain types of cases Answer: 1, 2, 3, 5 Rationale 1: The facility in the northern part of the United States will see more cases of hypothermia than the facility in the southern United States Rationale 2: There may be seasonal increases in illness, such as allergies and influenza Rationale 3: The facility may focus on certain conditions or client populations, such as a children’s facility Rationale 4: The facility will want the caregivers to document quickly, carefully and thoroughly Rationale 5: The physician may specialize in certain types of cases, and does not need to take time scrolling through other specialties Question 23 The Lists used in an EHR are created by: Standard Text: Select all that apply. 1. The CDC representatives 2. Facility Clinical Information Services 3. Nurses 4. Unlicensed assistive personnel 5. Clinicians Answer: 2, 3, 5 Rationale 1: The CDC is not involved with creating facility forms and lists Rationale 2: The facility CIS staff is involved in creating lists in the EHR Rationale 3: Nurses are involved in creating lists in the EHR Rationale 4: UAP are not involved in creating lists in the EHR, as they are not usually involved in documentation in the EHR Rationale 5: Clinicians are usually involved in creating lists in a facility Question 24 The nurse understands that ROS typically incorporates the following: Standard Text: Select all that apply. 1. It organizes an exam by body systems starting from the heart to the genitourinary system 2. It includes HEENT as one system 3. Documentation of symptoms that directly relate to the Chief complaint 4. Includes Emotions as a body system 5. Includes breast findings within the integumentary system Answer: 2, 5 Rationale 1: The ROS usually organizes an exam by body systems starting from the head down Rationale 2: The ROS usually groups the head, eyes, ears, nose, mouth, and throat as one system Rationale 3: Documentation of symptoms that relate to the Chief complaint are usually documented in the HPI Rationale 4: Any emotional symptoms are usually documented using “Psychiatric” as a system Rationale 5: Skin and breast findings are usually grouped together in the integumentary system Question 25 In many EHR systems, which of the following can be used to document normal findings quickly? 1. Forms 2. ROS 3. Auto Negatives 4. Lists Answer: 3 Rationale 1: Forms are used to group commonly used findings in one place Rationale 2: ROS is used to organize a physical exam Rationale 3: Auto Negatives will automatically populate selections with the normal finding Rationale 4: Lists group commonly used findings in one place Question 26 The nurse is documenting the Px of a client whose chief complaint is an upper respiratory illness. The Auto Negative populated the negative finding for fever in the ROS. The nurse takes the client’s temperature and notes that there is a mild fever. The appropriate actions include: Standard Text: Select all that apply. 1. Click on the (red button) No fever 2. Click on the (blue button) No fever 3. Select mild from the prefix menu 4. Select mild from the modifier menu 5. Click on the HPI button next to the finding Answer: 1, 4, 5 Rationale 1: Clicking on the (red button) will change the finding from no fever to fever Rationale 2: The (blue button) is already clicked on Rationale 3: The prefix menu is not used Rationale 4: The Modifier menu is used to select mild Rationale 5: Clicking on the HPI button next to the finding moves the finding from the ROS to the HPI Question 27 The nurse is recording the Sx and Px of a client with a chief complaint of dizziness. Using a list created for Syncope, the nurse understands that certain negative symptoms are: 1. Populated using Auto Negative 2. Are pertinent to the HPI 3. Used to create a longer encounter note 4. Used to modify findings Answer: 2 Rationale 1: Auto Negative may not be specific enough for certain chief complaints and symptoms Rationale 2: Certain negative symptoms are pertinent to the HPI; for example “no head symptoms” is a pertinent non-finding for syncope Rationale 3: A longer encounter note is not the purpose of pertinent negatives Question 28 Nurses use forms in order to: Standard Text: Select all that apply. 1. Speed data entry of positive and negative findings 2. Enable Entry Details field data 3. Group findings by a type of encounter 4. Group findings using the appropriate tab 5. Include fields required to meet regulatory requirements Answer: 1, 2, 3, 5 Rationale 1: Commonly assessed positive and negative findings can be grouped together in a form Rationale 2: Entry details can be included in a form, such as value or results Rationale 3: Forms can group findings by type of encounter, which decreases navigation time Rationale 4: Grouping findings by tab is a function of Lists Rationale 5: A form can include fields that are required to meet regulatory requirements; the forms designer has the option to require entry of data for certain findings before the form can be closed Question 29 When the nurse is filling out a form, checking an empty box 1. Removes a finding 2. Adds a finding 3. Moves the finding to the ROS 4. Opens the form Answer: 2 Rationale 1: Checking a full box removes that finding Rationale 2: Checking an empty box adds a finding Rationale 3: Checking a box in a form does not move it Rationale 4: Checking an empty box does not open or close the form Question 30 The nurse is entering an admission encounter on a client with a chief complaint consistent with an URI. Potential Forms and Lists that could speed documentation of the history and physical exam portions of the encounter include: Standard Text: Select all that apply. 1. Form for Surgical Intake 2. Form for Short intake 3. List for Respiratory Infections 4. List for Adult URI symptoms 5. Form for Respiratory Infections Answer: 2, 4 Rationale 1: A form for a Surgical Intake is not appropriate for this client Rationale 2: A form for a Short Intake is appropriate for this client Rationale 3: A list of Respiratory Infections is unlikely to be helpful Rationale 4: A list of Adult URI symptoms would speed entry of the history and symptoms and physical exam of this client Rationale 5: A form for Respiratory infections may not be helpful for an URI Test Bank for Electronic Health Records and Nursing Richard Gartee, Sharyl Beal 9780131383722, 9780132885522
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