CCS Medical Terminology & Documentation 2 — Questions and Answers
Question 1: A care note states the resident is 'dyspneic.' What does this term mean?
- Having difficulty swallowing
- Experiencing difficulty breathing (Correct answer)
- Complaining of chest pain
- Showing signs of confusion
Correct answer: Experiencing difficulty breathing
Dyspnea refers to shortness of breath or labored breathing, a common symptom documented in care records.
Question 2: Which abbreviation is used in care documentation to indicate a medication is given by mouth?
- IV
- IM
- PO (Correct answer)
- SQ
Correct answer: PO
PO stands for 'per os,' the Latin term meaning by mouth, used to indicate oral medication administration.
Question 3: A resident's chart notes 'edema in bilateral lower extremities.' What does this describe?
- Pain in both legs
- Swelling in both legs (Correct answer)
- Weakness in both arms
- Numbness in both feet
Correct answer: Swelling in both legs
Edema is the accumulation of fluid causing swelling, and 'bilateral lower extremities' refers to both legs.
Question 4: What does the medical prefix 'tachy-' mean?
- Slow
- Fast (Correct answer)
- Difficult
- Painful
Correct answer: Fast
The prefix 'tachy-' means fast or rapid, as in tachycardia (fast heart rate) or tachypnea (fast breathing).
Question 5: In documentation, the term 'prn' indicates a medication or treatment should be given:
- Every morning
- Twice daily
- As needed (Correct answer)
- At bedtime
Correct answer: As needed
PRN comes from the Latin 'pro re nata,' meaning as the situation demands or as needed.
Question 6: A care specialist documents that a resident is 'incontinent.' This means the resident:
- Is unable to walk independently
- Cannot control bladder or bowel function (Correct answer)
- Refuses to eat meals
- Has difficulty communicating
Correct answer: Cannot control bladder or bowel function
Incontinence is the inability to control bladder or bowel function, a common condition documented in long-term care settings.
Question 7: The suffix '-ectomy' at the end of a medical term indicates:
- Inflammation of an organ
- Surgical removal of a body part (Correct answer)
- A visual examination
- A disease condition
Correct answer: Surgical removal of a body part
The suffix '-ectomy' means surgical removal or excision, such as appendectomy (removal of the appendix).
CCS Medical Terminology & Documentation 2
A care note states the resident is 'dyspneic.' What does this term mean?