Patient Assessment & Documentation Flashcards
7 cards from real EMS 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
During a secondary assessment, you note that a patient's trachea is deviated to the left. What does this finding most likely indicate?
Answer: Tension pneumothorax on the right side
Tracheal deviation occurs away from a tension pneumothorax as pressure buildup shifts mediastinal structures to the opposite side.
When assessing a patient's mental status using the AVPU scale, which response is recorded if the patient only reacts to a sternal rub?
Answer: Pain
A sternal rub is a painful stimulus, so a patient who responds only to this is classified as 'P' (Pain) on the AVPU scale.
A PCR (Patient Care Report) must be completed within what standard timeframe in most EMS systems?
Answer: Before leaving the receiving facility
Best practice requires the PCR to be completed before leaving the receiving facility to ensure accurate, contemporaneous documentation.
Which component of the SAMPLE history asks about medications, allergies, and recent illnesses?
Answer: A, M, and P components together
SAMPLE stands for Signs/symptoms, Allergies, Medications, Pertinent medical history, Last oral intake, and Events — allergies, medications, and past history are separate components.
During a scene size-up of a motor vehicle collision, you observe downed power lines across the vehicle. What is your first action?
Answer: Stage at a safe distance and contact the power company
Energized downed power lines create a lethal scene hazard; EMS must stage safely and await utility personnel before approaching.
When documenting a patient's blood pressure of 118/76 mmHg, which value represents the diastolic pressure?
Answer: 76 mmHg
Blood pressure is recorded as systolic over diastolic; the lower number (76 mmHg) is the diastolic pressure reflecting ventricular relaxation.
A conscious 60-year-old male complains of crushing chest pain radiating to his jaw. His skin is pale and diaphoretic. Which assessment finding best supports a cardiac emergency?
Answer: 12-lead ECG showing ST-segment elevation
ST-segment elevation on a 12-lead ECG is the hallmark finding of an ST-elevation myocardial infarction (STEMI), confirming a cardiac emergency.