Chapter 8 Flashcards
Which of the following findings is an objective finding made during a patient assessment?
a. Patient’s complaint of nausea
b. Blood pressure of 114/68 mmHg
c. Patient’s rating of pain as 10 out of 10
d. Patient’s complaint of headache for the past 12 hours
a. Patient’s complaint of nausea
b. Blood pressure of 114/68 mmHg
c. Patient’s rating of pain as 10 out of 10
d. Patient’s complaint of headache for the past 12 hours
Answer: b
Objective: 8-3
Reference: 283
A nauseated patient’s report of abdominal pain should be documented:
a. as a treatment finding.
b. as a subjective finding.
c. as an objective finding.
d. This information need not be documented.
a. as a treatment finding.
b. as a subjective finding.
c. as an objective finding.
d. This information need not be documented.
Answer: b
Objective: 8-3
Reference: 283
A patient tells you that he has been feeling “very weak” for the past three days. In regards to the SOAP charting format, this information would be included under what heading?
a. S
b. O
c. A
d. P
a. S
b. O
c. A
d. P
Answer: a
Objective: 8-3
Reference: 277
You have placed a 67-year-old female patient on high-concentration oxygen via nonrebreather face mask. Following the acronym CHEATED where is it appropriate to document the information concerning the oxygen administration?
a. A
b. H
c. T
d. C
a. A
b. H
c. T
d. C
Answer: c
Objective: 8-3
Reference: 278
When asked, an alert and oriented 44-year-old man with a history of high blood pressure reports that he called for help because “my chest is hurting.” He is diaphoretic and nauseated, has a pulse of 88 and a BP of 156/92, and says that his pain “feels just like my heart attack two years ago.” Based on this information, how would you document his chief complaint on the patient care report?
a. “My chest is hurting.”
b. Possible heart attack
c. Myocardial infarction
d. Chest pain with hypertension
a. “My chest is hurting.”
b. Possible heart attack
c. Myocardial infarction
d. Chest pain with hypertension
Answer: a
Objective: 8-4
Reference: 277
An intoxicated patient will not leave the oxygen mask on. You are aware that the acronym FACTUAL-OEC outlines the characteristics of good report writing. Based on these guidelines how would this best be documented on the prehospital care report (PCR)?
a. The patient is intoxicated and will not cooperate with oxygen therapy.
b. The patient continually removes the oxygen mask despite continued reapplication.
c. The patient will not cooperate with care provided by the ski patrol.
d. The patient appears to be in a drunk-like state and will not cooperate with care provided by the ski patrol.
a. The patient is intoxicated and will not cooperate with oxygen therapy.
b. The patient continually removes the oxygen mask despite continued reapplication.
c. The patient will not cooperate with care provided by the ski patrol.
d. The patient appears to be in a drunk-like state and will not cooperate with care provided by the ski patrol.
Answer: b
Objective: 8-4
Reference: 278
A patient states that he has had a headache located in his forehead for three days. Utilizing the SOAP format you would document this piece of information as a(n):
a. subjective finding.
b. pertinent negative.
c. objective finding.
d. provoking factor.
a. subjective finding.
b. pertinent negative.
c. objective finding.
d. provoking factor.
Answer: a
Objective: 8-3
Reference: 277
When writing a prehospital care report, you accidentally document a laceration as being on the left side of a patient’s face when it was actually on the right side of the face. In addition to putting your initials and current date/time next to your correction, you would change your documentation in which of the following ways?
a. Color over the word “left” with black ink and write the word “right” next to it.
b. Write the word “error” through the word “left” and then write the word “right” next to it.
c. Use correction fluid to cover the word “left” and write the word “right” next to it.
d. Draw a single line through the word “left” and write the word “right” next to it.
a. Color over the word “left” with black ink and write the word “right” next to it.
b. Write the word “error” through the word “left” and then write the word “right” next to it.
c. Use correction fluid to cover the word “left” and write the word “right” next to it.
d. Draw a single line through the word “left” and write the word “right” next to it.
Answer: d
Objective: 8-5
Reference: 279
Two days after a call, you realize that you forgot to document that you checked a patient’s pupils before the patient refused further treatment and signed a refusal form. Which of the following actions is your best course of action?
a. Complete a new refusal form and include the additional information.
b. Add an addendum to the report that contains the correct information, the current date, and your signature.
c. Report the error to your patrol director and have him/her take care of it.
d. Don’t worry about it because it did not seem to matter to the patient.
a. Complete a new refusal form and include the additional information.
b. Add an addendum to the report that contains the correct information, the current date, and your signature.
c. Report the error to your patrol director and have him/her take care of it.
d. Don’t worry about it because it did not seem to matter to the patient.
Answer: b
Objective: 8-5
Reference: 279
For which of the following patients must you provide care even if the patient refuses it?
a. A 23-year-old female with an obvious injury who lives with her parents and her one-year-old daughter
b. An alert and oriented 57 year old who is having chest pain and is diaphoretic
c. A six year old with a bleeding head laceration, whose parent will not allow care
d. A 29-year-old female who fell and cannot tell you what day it is
a. A 23-year-old female with an obvious injury who lives with her parents and her one-year-old daughter
b. An alert and oriented 57 year old who is having chest pain and is diaphoretic
c. A six year old with a bleeding head laceration, whose parent will not allow care
d. A 29-year-old female who fell and cannot tell you what day it is
Answer: d
Objective: Supplemental
Reference: 284
You are alone responding to an alert and oriented male with chest discomfort who refuses treatment. He is angry with his family for calling for help and will not sign the refusal form despite several requests. In addition to documenting that the patient understands and accepts the risks of refusing care, you would:
a. contact the police to place the patient into protective custody.
b. have a family member sign as a witness to the man’s refusal.
c. carefully restrain the man and transport him to the aid room.
d. call for an ALS ambulance and have the paramedics treat the patient.
a. contact the police to place the patient into protective custody.
b. have a family member sign as a witness to the man’s refusal.
c. carefully restrain the man and transport him to the aid room.
d. call for an ALS ambulance and have the paramedics treat the patient.
Answer: b
Objective: 8-6
Reference: 284
When getting a refusal from a patient who does not want treatment, it is critical that you do which of the following things?
a. Ensure that the patient understands the risks of refusing care.
b. Make sure the patient has someone who can provide transportation to the hospital.
c. Have the patient sign and date the refusal form.
d. Have the patient promise to get care if the symptoms get worse.
a. Ensure that the patient understands the risks of refusing care.
b. Make sure the patient has someone who can provide transportation to the hospital.
c. Have the patient sign and date the refusal form.
d. Have the patient promise to get care if the symptoms get worse.
Answer: a
Objective: 8-6
Reference: 284
Which of the following statements about prehospital care reports is accurate?
a. They may become part of the patient’s permanent medical record.
b. They are forms published by the NSAA or the ski area’s insurance company.
c. National standards allow up to three days after the accident for the forms to be fully completed.
d. You should only document the care provided to the patient but not scene information, because the latter can be confusing.
a. They may become part of the patient’s permanent medical record.
b. They are forms published by the NSAA or the ski area’s insurance company.
c. National standards allow up to three days after the accident for the forms to be fully completed.
d. You should only document the care provided to the patient but not scene information, because the latter can be confusing.
Answer: a
Objective: Supplemental
Reference: 273
The goal of effective communication is to:
a. give as much information as possible in less than three minutes.
b. deliver information in a manner that is understood by the recipient.
c. speak clearly and more slowly than normal so that you are easier to understand.
d. use medical terminology as much as possible.
a. give as much information as possible in less than three minutes.
b. deliver information in a manner that is understood by the recipient.
c. speak clearly and more slowly than normal so that you are easier to understand.
d. use medical terminology as much as possible.
Answer: b
Objective: Supplemental
Reference: 267
Written medical communications are generally used for all of the following except:
a. for quality-improvement activities.
b. to transmit information to the provider who is taking over care of a patient.
c. when giving press releases about mountain accidents.
d. for describing ways to improve the safety of outdoor activities.
a. for quality-improvement activities.
b. to transmit information to the provider who is taking over care of a patient.
c. when giving press releases about mountain accidents.
d. for describing ways to improve the safety of outdoor activities.
Answer: c
Objective: Supplemental
Reference: 271
