Describe the parts of the Medical Record
What will be an ideal response?
• History and Physical—details the patient's history, results of the physician's examination, initial diagnoses, and physician's plan of treatment
• Physician's Orders—a complete list of the care, medications, tests, and treatments the physician orders for the patient
• Nurse's Notes—record of the patient's care throughout the day
• Physician's Progress Notes—the physician's daily record of the patient's condition, results of the physician's examinations, summary of test results, updated assessment and diagnoses, and further plans for the patient's care
• Consultation Report—the report given by a specialist whom the physician has asked to evaluate the patient
• Ancillary Reports—reports from various treatments and therapies the patient has received
• Diagnostic Reports—results of all diagnostic tests performed on the patient
• Informed Consent—a document voluntarily signed by the patient or a responsible party that clearly describes the purpose, methods, procedures, benefits, and risks of a diagnostic or treatment procedure
• Operative Report—report from the surgeon detailing an operation
• Anesthesiologist's Report—relates the details regarding the drugs given to a patient, the patient's response to anesthesia, and vital signs during surgery
• Pathologist's Report—the report given by a pathologist who studies tissue removed from the patient
• Discharge Summary—a comprehensive outline of the patient's entire hospital stay
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The nurse is reviewing the medical records of different clients
Client Client 1 Client 2 Client 3 Client 4 Gender Male Female Male Female Waist circumference 38 inches 37 inches 32 inches 30 inches Triglyceride levels 100 mg/dL 160 mg/dL 130 mg/dL 120 mg/dL Which client does the nurse expect to have metabolic syndrome? 1. Client 1 2. Client 2 3. Client 3 4. Client 4
Which medication causes the pupil to constrict?
A) antiemetic B) miotic C) emulsifier D) mydriatic
List and describe three negative short-term side effects of smoking tobacco. Additionally, list and describe three long-term side effects of smoking tobacco.
What will be an ideal response?
Which of the following tests does NOT indicate that the subclavian artery is being compressed?
A. Adson sign test B. Hyperabduction syndrome test C. Costoclavicular syndrome test D. Impingement syndrome test