CCS Medical Terminology & Documentation 3 — Questions and Answers
Question 1: A care plan uses the term 'ambulation.' This refers to a resident's ability to:
- Eat independently
- Walk or move about (Correct answer)
- Communicate verbally
- Perform self-care tasks
Correct answer: Walk or move about
Ambulation refers to the act of walking or moving from place to place, a key functional assessment in care planning.
Question 2: Which term describes a wound that is healing properly with new tissue formation?
- Necrotic
- Granulating (Correct answer)
- Macerated
- Escharotic
Correct answer: Granulating
Granulation tissue is new connective tissue and blood vessels that form on a wound surface during healing.
Question 3: When documenting vital signs, the abbreviation 'BP' refers to:
- Body positioning
- Bladder pattern
- Blood pressure (Correct answer)
- Breathing pattern
Correct answer: Blood pressure
BP stands for blood pressure, the force of blood pushing against artery walls, measured in mmHg.
Question 4: A resident's chart contains the word 'dysphagia.' This refers to difficulty with:
- Breathing
- Walking
- Swallowing (Correct answer)
- Speaking
Correct answer: Swallowing
Dysphagia is difficulty swallowing, a condition that requires special dietary modifications and documentation in care plans.
Question 5: In a resident's medical record, 'NPO' means the resident should:
- Receive only liquid medications
- Have nothing by mouth (Correct answer)
- Be monitored every hour
- Receive nutritional supplements
Correct answer: Have nothing by mouth
NPO stands for 'nil per os,' Latin for nothing by mouth, commonly ordered before surgery or certain medical procedures.
Question 6: A care note describes a pressure injury as 'Stage II.' This means the wound involves:
- Only redness of intact skin
- Partial thickness skin loss with exposed dermis (Correct answer)
- Full thickness skin loss exposing fat
- Full thickness tissue loss with exposed bone
Correct answer: Partial thickness skin loss with exposed dermis
Stage II pressure injuries involve partial thickness skin loss with exposed dermis, appearing as a shallow open ulcer or intact blister.
Question 7: Which term is used to document a resident's mental state and alertness level?
- Prognosis
- Diagnosis
- Level of consciousness (Correct answer)
- Chief complaint
Correct answer: Level of consciousness
Level of consciousness (LOC) describes the degree to which a person is aware of and responsive to their environment.
CCS Medical Terminology & Documentation 3
A care plan uses the term 'ambulation.' This refers to a resident's ability to: