CCS Medical Terminology & Documentation 2

Question 1

A care note states the resident is 'dyspneic.' What does this term mean?

Accepted Answer

Experiencing difficulty breathing

Answer

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?

Accepted Answer

PO

Answer

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?

Accepted Answer

Swelling in both legs

Answer

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?

Accepted Answer

Fast

Answer

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:

Accepted Answer

As needed

Answer

PRN comes from the Latin 'pro re nata,' meaning as the situation demands or as needed.

(CCS) Certified Care Specialist Practice Test