DC Patient Assessment & Documentation 3 — Questions and Answers
Question 1: A patient with atrial fibrillation reports a syncopal episode. Which additional assessment should be prioritized and documented?
- Dietary sodium intake over the past week
- Neurological status and blood pressure (Correct answer)
- Exercise tolerance from 6 months ago
- Occupational history
Correct answer: Neurological status and blood pressure
Syncope in AF may indicate hemodynamic compromise or thromboembolic event, making neurological status and BP critical assessments.
Question 2: When performing a focused cardiac assessment on a dysrhythmia patient, auscultation of heart sounds is important primarily to detect:
- Bowel sounds indicating GI issues
- Murmurs or S3/S4 gallops suggesting structural heart disease (Correct answer)
- Lung compliance changes only
- Respiratory rate abnormalities
Correct answer: Murmurs or S3/S4 gallops suggesting structural heart disease
Murmurs and extra heart sounds can indicate structural conditions (e.g., valvular disease, heart failure) that predispose to dysrhythmias.
Question 3: Which electrolyte abnormality should always be assessed and documented in a patient presenting with a new dysrhythmia?
- Serum calcium only
- Potassium and magnesium levels (Correct answer)
- Sodium bicarbonate only
- Phosphate levels only
Correct answer: Potassium and magnesium levels
Hypokalemia and hypomagnesemia are common causes of dysrhythmias and must be identified and corrected.
Question 4: In documenting a rhythm strip, how should a change in patient condition coinciding with a rhythm change be recorded?
- In a separate log with no reference to the strip
- Contemporaneously on the strip and in the clinical notes with timestamp (Correct answer)
- Only verbally reported to the supervising physician
- Documented at the end of the shift
Correct answer: Contemporaneously on the strip and in the clinical notes with timestamp
Contemporaneous documentation linking rhythm changes to clinical events provides an accurate, legally defensible clinical record.
Question 5: Which of the following best describes the purpose of the SAMPLE history framework in dysrhythmia patient assessment?
- To assess respiratory function only
- To systematically gather Signs/Symptoms, Allergies, Medications, Pertinent history, Last intake, and Events (Correct answer)
- To document only the patient's medication list
- To collect insurance information
Correct answer: To systematically gather Signs/Symptoms, Allergies, Medications, Pertinent history, Last intake, and Events
SAMPLE is a structured approach that ensures comprehensive history collection relevant to the patient's current presentation.
Question 6: A patient on digoxin presents with bradycardia. What specific documentation is critical in this scenario?
- The brand of digoxin prescribed only
- Digoxin dose, last dose time, serum digoxin level, and current heart rate and rhythm (Correct answer)
- Only the pharmacy dispensing record
- The patient's self-reported compliance without lab values
Correct answer: Digoxin dose, last dose time, serum digoxin level, and current heart rate and rhythm
Digoxin toxicity causes bradydysrhythmias, so documenting dose, timing, serum level, and rhythm is essential for safe management.
Question 7: Which physical assessment finding, when documented in a dysrhythmia patient, suggests the presence of heart failure as a complicating factor?
- Normal skin turgor
- Bilateral crackles on lung auscultation and jugular venous distension (Correct answer)
- Capillary refill under 2 seconds
- Regular bowel sounds
Correct answer: Bilateral crackles on lung auscultation and jugular venous distension
Bilateral crackles and JVD are classic signs of heart failure, which frequently coexists with and exacerbates dysrhythmias.
DC Patient Assessment & Documentation 3
A patient with atrial fibrillation reports a syncopal episode.
Which additional assessment should be prioritized and documented?