Chapter 4

Question 1

A patient with asthma is using his inhaler TID and prn. You would recognize​ that:

Answer 1

The patient uses an inhaler at least three times a day.

Question 2

You have transferred care of a​ 21-year-old woman who overdosed on an unknown drug. For the​ patient, which best describes who is permitted access to the prehospital care report​ (PCR)?

Answer 2

The healthcare provider assuming care of the patient

Question 3

After oxygen​ therapy, the​ patient’s SpO2 improves from​ 90% to​ 99%. Using the CHEATED method of​ documentation, this information would be placed in which​ category?

Answer 3

Evaluation

Question 4

What would be considered an objective patient assessment​ finding?

Answer 4

Blood pressure​ 114/68 mmHg

Question 5

Just before the end of their​ shift, EMTs transported a young male who bystanders state​ “passed out” and then had a seizure.​ Now, an hour​ later, the patient has been stabilized and the physician asks the nurse if she knows what the seizure looked like. To easily answer this​ question, she​ would:

Answer 5

Check the prehospital care report

Question 6

You have transported a confused​ 46-year-old male who overdosed on an unknown drug to a busy emergency department. After giving an oral report to the Emergency Department​ (ED) nurse, your partner informs you that he wants to hurry back to the station so that he can watch the end of the football​ game; therefore, he is going to complete the patient care report​ (PCR) at a later time. How should you​ respond?

Answer 6

“If you do not complete and leave the​ PCR, the ED staff may not otherwise have access to information contained in the PCR which may impact patient​ care.”

Question 7

A patient states that he has had a headache located in his forehead for three days. The EMT should recognize and document this piece of information as​ a(n):

Answer 7

Subjective finding

Question 8

The medical director for your service has put you in charge of designing a new prehospital care report form. He states that it must contain the​ “minimum data​ set” as set forth by the U.S. Department of Transportation. In completing this​ task, you realize that incorporating these data into your report form​ will:

Answer 8

Allow easier comparison of specific EMS data between various types of emergency systems

Question 9

A nauseated patient with fever and abdominal pain states that he has not vomited. Which description best represents how that fact should be​ documented?

Answer 9

As a pertinent negative

Question 10

A patient care report​ reads: “c/o fall with​ (R) hip​ pain; FROM to​ (R) low.​ ext.” Based on​ this, you should recognize that the​ patient’s:

Answer 10

Right leg can be moved normally

Question 11

When​ asked, an alert and oriented​ 44-year-old male tells you that he called 911 because​ “my chest is​ hurting.” The man is also sweating and feels as if he is going to vomit. He has a history of high blood pressure and states that this pain​ “feels just like my heart attack two years​ ago.” His pulse is 88 beats per​ minute, respirations are 18 breaths per​ minute, and blood pressure is​ 156/92 mmHg. On room​ air, he has an oxygen saturation level of 95 percent. Based on this​ information, how would you document his chief complaint on the patient care​ report?

Answer 11

“My chest is​ hurting.”

Question 12

A patient states that he has suffered from chronic neck pain ever since an accident.​ Further, he states that he is filing a lawsuit against the EMTs since they failed to put a cervical collar on him at the​ time; in his​ eyes, this is the reason he has daily neck and back pain. The EMT can remember the incident well and remembers placing a cervical collar on the patient. As​ such, his best defense would​ be:

Answer 12

Written documentation of cervical collar placement on the patient care report​ (PCR)

Question 13

The medical director states that it seems as if the number of patients suffering from shortness of breath with a history of congestive heart failure​ (CHF) has increased. She adds that she is thinking about modifying the​ protocols, but first must know the number of patients seen with this condition over the past year. To best determine the number of patients treated for this​ condition, you​ would:

Answer 13

Review the previous prehospital care reports

Question 14

Consider this narrative from a patient care​ report: “pt. restrained passenger involved in 2 car​ MVC; c/o left lower leg pain rated​ 2/10; LOC is​ A/O to​ person, place,​ time, and​ event; BBS​ +; abd. Soft with tenderness​ LLQ; hx of NIDDM with am glucose level of 133​ mg/dL.” Which of these interpretations is most​ accurate?

Answer 14

The​ patient’s lungs sounds are present bilaterally.

Question 15

A patient care report​ reads: “c/o CP with associated​ DOE; PMH of​ IDDM, CAD,​ & ARF.” Regarding this​ description, which interpretation is most​ accurate?

Answer 15

The patient has diabetes.

Question 16

When completing a​ paper-based prehospital care​ report, you accidentally write that a laceration was on the left side of a​ patient’s face when it was actually on the right side of the face. Correcting this mistake would include which​ step?

Answer 16

Draw a single line through the term​ “left” and write the word​ “right” next to it.

Question 17

While moving a​ 67-year-old male who complains of dizziness from his residence on the​ stretcher, you stumble backward and knock a vase from a​ table, causing it to break. The patient and family are very upset with the damage. In the​ process, you hurt your ankle and are having a hard time walking. When completing the prehospital care report​ (PCR), what should be​ included?

Answer 17

An objective statement about the​ family’s displeasure

Question 18

Your partner states that he is the​ “world’s worst​ speller” and has great difficulty using medical terms. How would you respond to this​ statement?

Answer 18

“Use everyday language if you are unsure of how to apply or spell a medical​ term.”

Question 19

Which statement regarding a patient care report​ (PCR) is​ accurate?

Answer 19

“Aside from providing a record of the care​ given, the PCR also may be used for education and​ research.”

Question 20

After a​ patient, who is short of​ breath, signs a refusal of service​ form, which statement would be appropriate prior to leaving the​ residence?

Answer 20

“If you change your mind at any time and want to be transported to the​ hospital, call 911​ again.”

Question 21

In order to better assure that Medicare will pay for the transport of an elderly patient with​ weakness, what is one component that the EMT should be certain to include in the​ PCR?

Answer 21

Justification as to why the patient could not be transported by a lesser means of transport other than an ambulance.

Question 22

You have been called to the house of a patient with altered mental status. You encounter a​ 41-year-old male who exhibits slurred​ speech, an unsteady​ gait, and an odor resembling that of alcohol on his breath. His wife states that he is an alcoholic and needs help to get better. When documenting this​ information, which statement would be​ best?

Answer 22

Per wife-patient has alcoholic history

Question 23

You are involved in a lawsuit over a stabbing that occurred six months ago. Since you work in a busy EMS system and some time has​ passed, your recollection of the incident in spotty. In this​ situation, your best means of remembering what occurred would be​ to:

Answer 23

Review the prehospital care report

Question 24

You are reviewing a prehospital care report​ (PCR) and find this​ entry: “Pt. took PCN TID PO for 5​ days.” You would interpret this as the patient​ took:

Answer 24

Penicillin was taken orally three times a day for five days straight

Question 25

You have placed a​ 67-year-old female patient on​ low-concentration oxygen with a nasal cannula. Under which section of the prehospital care report​ (PCR) would you document this​ information?

Answer 25

Treatment

Question 26

Which item is included in the U.S. Department of Transportation minimum data​ set?

Answer 26

Vital signs and skin condition

Question 27

Consider this narrative from a patient care​ report: “pt. transported 3 days ago for suspected​ STEMI; pt. currently denies CP and​ SOB; PMH of HTN and​ CAD; pt. currently in​ NAD.” Which of these interpretations is most​ accurate?

Answer 27

The patient has heart problems.

Question 28

A pertinent negative would be illustrated​ by:

Answer 28

“Nausea without​ vomiting.”

Question 29

What is meant by the​ “prudent layperson”​ standard?

Answer 29

A method to help insurance companies determine if they will pay for an ambulance transport or not.

Question 30

What would be the best reason for a policy that requires all crew members to synchronize their watches with dispatch at the beginning of each​ shift?

Answer 30

Promotes accurate​ system-wide time record keeping throughout the shift

Question 31

When getting a refusal from a patient who does not want the services of EMS​ providers, it is critical for the EMT to complete which​ step?

Answer 31

Have the patient sign and date the refusal form.

Question 32

You have been called for a​ 2-year-old female with an arm injury. The child presents with deformity and bruising to her left forearm. When​ asked, the mother states that the child fell from the​ bed, but the father states that his daughter fell down the stairs. Given the inconsistent​ stories, you are suspicious of child abuse. Which narrative would be most appropriate when documenting this​ situation?

Answer 32

“Patient fell off of bed injuring left arm per​ mother; patient fell downstairs injuring left arm per​ father.”

Question 33

Immediately after giving a prehospital care report to the nurse in the emergency​ department, dispatch informs you that there are no more ambulances available and you must immediately leave the hospital to cover another portion of the county. Since your service uses a computerized documentation system and there is no time to complete your​ report, your best course of action should be​ to:

Answer 33

Complete an abbreviated​ transfer-of-care report.

Question 34

You document this statement on the prehospital care​ report: “c/o​ H/A with associated​ n/v; pt. denies existing CNS problems or history of the​ same; states positive history of AAA and ETOH​ abuse.” Regarding this​ narrative, which interpretation would be most​ accurate?

Answer 34

The patient has a headache.

Question 35

Which statement describes an advantage of computerized​ documentation?

Answer 35

Large amounts of data can be stored and retrieved much more easily than with handwritten PCRs.

Question 36

Last​ week, you accidentally documented on a patient care report that a patient suffered from hypertension​ when, in​ fact, he did not. Your first action to remedy this oversight would be​ to:

Answer 36

Obtain the original and draw a line through the error.

Question 37

A prehospital care report​ reads: “GSW to​ LLQ.” Based on​ this, you should recognize that the patient sustained​ a(n):

Answer 37

Gunshot to the lower left abdomen

Question 38

A patient tells you that he has been feeling​ “very weak” for the past three days. Using the SOAP charting​ format, this information would be included under which​ heading?

Answer 38

Subjective

Question 39

Your protocol​ reads: ​”O2 via NC prn if symptomatic for CP​ / SOB​ & SpO2​ < 94%.” To follow this​ order, you should perform which​ action?

Answer 39

Consider oxygen for a patient complaining of chest pain if the SpO2 is​ 92%.

Question 40

Two days after a​ call, you realize that you forgot to document that you checked a​ patient’s blood glucose prior to him refusing transport and signing the refusal form. At that​ time, you did contact medical direction and provide this information to the​ doctor, prior to him authorizing the patient to refuse. What is now your best course of​ action?

Answer 40

Add an addendum to the report with the correct​ information, the current​ date, and the​ EMT’s initials

Question 41

An alert and oriented male patient with chest discomfort refuses treatment and transport to the hospital. He is angry with his family for calling 911 and refuses to sign the refusal of care form despite several requests. Which of these is your next best​ action?

Answer 41

Have a family member sign as a witness to the​ father’s refusal.

Question 42

Which item would the EMT place in the administrative information section of the prehospital care​ report?

Answer 42

BLS Unit​ 204; Incident​ # 67-8971-90

Question 43

A patient care report​ reads: “PMH includes ESRD and​ (+) DNR;​ (+) ASA pta of​ EMS.” Regarding this​ description, which interpretation is most​ accurate?

Answer 43

The patient has kidney disease.

Question 44

An intoxicated patient will not leave the oxygen mask on. What would be the most appropriate way to document this behavior on the prehospital care​ report?

Answer 44

The patient continually removes the oxygen mask despite continued verbal redirection and reapplication.