Patient Assessment & Documentation Flashcards
7 cards from real CCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Assessment & Documentation flashcards as text
When documenting a patient's chest pain, which PQRST element addresses what makes the pain better or worse?
Answer: P - Provocation/Palliation
The 'P' in PQRST stands for Provocation/Palliation, capturing aggravating and relieving factors for chest pain.
A patient presents with bilateral pitting edema to the ankles. How should this finding be graded using the standard 4-point scale?
Answer: Grade the depth of the pit and time to rebound
Pitting edema is graded 1+ to 4+ based on pit depth (2–8 mm) and rebound time (rapid to >20 seconds).
Which component of the cardiovascular history is most important when assessing a patient's risk for sudden cardiac death?
Answer: Family history of sudden cardiac death or arrhythmia
A family history of sudden cardiac death or inherited arrhythmia syndromes (e.g., Long QT, HCM) is the strongest heritable risk factor for SCD.
During auscultation, an S3 gallop is most commonly associated with which condition?
Answer: Heart failure with reduced ejection fraction
An S3 gallop reflects rapid ventricular filling in a dilated, poorly compliant ventricle and is a hallmark of systolic heart failure.
A CCS is reviewing a patient's medication reconciliation. Which cardiovascular medication requires documentation of the patient's pulse rate before administration?
Answer: Digoxin
Digoxin has a narrow therapeutic window and should be withheld if the apical pulse is below 60 bpm, requiring pre-dose pulse documentation.
When recording a blood pressure of 158/94 mmHg in a patient's chart, per ACC/AHA 2017 guidelines, this reading is classified as:
Answer: Stage 2 Hypertension
Per 2017 ACC/AHA guidelines, Stage 2 Hypertension is defined as SBP ≥140 mmHg or DBP ≥90 mmHg.
A patient reports dyspnea that awakens them from sleep and is relieved by sitting upright. This symptom should be documented as:
Answer: Paroxysmal nocturnal dyspnea
Paroxysmal nocturnal dyspnea (PND) is sudden breathlessness that wakes a patient from sleep and is relieved by sitting or standing up.