EMR: Medical History and Vital Signs

You are caring for an adult patient who appears unconscious. When you tap his shoulder and call out his name, he opens his eyes and attempts to respond. This patient would be classified as ___________ on the AVPU scale.

• alert

• verbal

• painful

• unresponsive

In a SAMPLE history, the E represents:

• EKG results

• evaluation of the neck and spine

• events leading to the illness or injury

• evidence of airway obstruction

When assessing circulation for a responsive adult patient, you should assess the:

• carotid pulse

• radial pulses on both

• radial pulse on either side

• brachial pulse

Finding a radial pulse in an infant is difficult, so a ________ pulse is more commonly taken.

• femoral

• brachial

• carotid

• pedal

Cyanosis is a sign of:

• liver disease.

• distress.

• high fever.

• severe hypoxia

A capillary refill test is considered to be most accurate when used with which age group?

• Under 6 years old

• Adolescents

• Elderly, over 60 years old

• Middle age, between 30 and 50 years

The process of comparing multiple sets of vital signs from the same patient over time is called:

• measuring.

• trending.

• estimating.

• baseline

The normal pupil reaction to a penlight is to:

• dilate

• remain the same size.

• constrict

• fluctuate.

A finding that is relayed from the patient but that cannot be observed or measured is a(n):

• sign.

• suspicion of cause.

• symptom.

• objective discovery.

The “P” in SAMPLE history stands for:

• past medical history.

• pharmaceuticals used.

• present illnesses.

• primary complaint