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Bio-Medical > CH 7 > Flashcards

CH 7 Flashcards

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Biology 101 flashcards USMLE® Step 1 flashcards
1
Q

An electronic version of a person’s medical record is _________; also called electronic medical record.

A

Electronic Health Record

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2
Q

Another term for medical record is ______.

A

Clinical Record

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3
Q

At or toward the front of the body or body part is ventral or _______.

A

Anterior

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4
Q

A ____ is a word element placed after a root; it changes the meaning of the word.

A

Prefix

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5
Q

At the side of the body or body part is ______.

A

Lateral

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6
Q

An ______ is a shortened form of a word or phrase.

A

Abbreviation

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7
Q

A part of a word us a _____.

A

Word Element

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8
Q

A _____ is a type of card file that summarizes information found in the medical record.

A

Kardex

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9
Q

The medical record is also called the _____.

A

Chart

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10
Q

The part nearest to the center or the point of origin is _______.

A

Medial

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11
Q

_______ is the exchange of information- a message sent is receive and interpreted by the intended person.

A

Communication

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12
Q

Another term for anterior is ______.

A

Ventral

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13
Q

A written account of a person’s condition and response to treatment and care is the chart or _______.

A

Recording

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14
Q

______ is at or toward the back of the body or body part; posterior.

A

Dorsal

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15
Q

The oral account of care and observations is ______.

A

Reporting

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16
Q

_____ is the part farthest from the center or from the point of attachment.

A

Distal

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17
Q

A word element placed before a root is the ____. It changes the meaning of the word.

A

Prefix

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18
Q

A word element containing the basic meaning of the word is the ______.

A

Root

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19
Q

Another word for dorsal is ______.

A

Posterior

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20
Q

_____ is the written account of care and observation.

A

Recording

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21
Q

_____ is at or near the muddle or mid-line of the body or body part.

A

Medial

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22
Q

_______ describes the care given and the person’s response and progress.

A

Progress Note

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23
Q

Another name for an electronic health record is __________.

A

Electronic Medical Record

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24
Q

A report that the nurse gives at the end of the shift to the on-coming staff is __________.

A

End of Shift Report

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25
Q

When health team members communicate, they share all of this information except?

A

Gossip about the person and his family

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26
Q

A nursing assistant tells the nurse that Mrs. Jones ate a small amount of his lunch. The nurse what?

A

Asks for further informaton because words may have different meanings to different people.

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27
Q

When giving information to another health team member is what?

A

Be brief and concise to reduce omitting important details

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28
Q

The medical record or chart is?

A

A permanent legal document

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29
Q

Which of these is not included in the person’s chart?

A

The daily menu

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30
Q

A nursing assistant must know what?

A

Must know the agency policy before reading the chart

31
Q

If a person asks to see his or her record, the nursing assistant reports what?

A

The request to the nurse

32
Q

The admission record contains what?

A

The name, birth date, age, and gender of the person

33
Q

The health history is completed when?

A

The person is admitted

34
Q

The nurse records the person’s reason for seeking health care in the what?

A

Health history

35
Q

Vital signs taken every shift are recording in the what?

A

Graphic sheet

36
Q

In long-term care, OBRA requires a written summary of the person when?

A

Every 3 months

37
Q

A weekly care record that has boxes for each day of the week is used in what?

A

Home care

38
Q

What is the Kardex?

A

A quick, easy source of information about the person

39
Q

The nursing assistant reports information about the person when?

A

There is a change in the person’s condition

40
Q

During the end-of-shift report, call lights, care, and routine tasks are usually done by who?

A

By the staff going off duty

41
Q

The general rules for recording include all of these except?

A

Use ditto marks needed

42
Q

If you are recording using the 24-hour clock, which of these is correct?

A

1300

43
Q

I a person points to the left side of his body below the umbilicus and tells you he has pain, you will tell the nurse he has pain in the what?

A

Left lower quadrant

44
Q

When describing the position of body parts, the hands and fingers are what?

A

Distal

45
Q

When you are given a computer password, what should you do?

A

You should never tell anyone your password

46
Q

The agency computers should not be used to what?

A

Send e-mails that require immediate reporting

47
Q

Privacy is protected when you what?

A

Prevent others from seeing what is on the screen

48
Q

When you answer the telephone, do not put the caller on hold if what?

A

The person has an emergency

49
Q

When you answer a phone when giving home care you should what?

A

Simply answer with “Hello”

50
Q

Slow heart rate

A

Bradycardia

51
Q

Difficulty urinating

A

Dysuria

52
Q

Blue color or condition

A

Cyanosis

53
Q

Rapid breathing

A

Tachypnea

54
Q

Opening into the trachea

A

Tracheostome

55
Q

Inflammation of kidneys

A

Nephritis

56
Q

Joint examination with a scope

A

Arthroscope

57
Q

Pertaining to blue coloration

A

Cyanotic

58
Q

Study of the skin

A

Dermatology

59
Q

Incision into large intestine

A

Colostomy

60
Q

Instrument used to examine bronchi

A

Colostomy

61
Q

Inflammation of the tongue

A

Glossitis

62
Q

Nerve pain

A

Neuralgia

63
Q

Examination of rectum with instrument

A

Proctoscopy

64
Q

Excision of gallbladder

A

Cholecystectomy

65
Q

Excision of ovary

A

Oophorectomy

66
Q

Incision into stomach

A

Gastrostomy

67
Q

Inflammation of stomach

A

Gastritis

68
Q

Inflammation of intestine

A

Enteritis

69
Q

ADL

A

Activities of Daily Living

70
Q

CBC

A

Complete Blood Count

71
Q

FBS

A

Fasting Blood Sugar

72
Q

LOC

A

Level of Consciousness

73
Q

ROM

A

Range of Motion

Bio-Medical (4 decks)

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