A secondary assessment consists of which of the following three steps?
a. Medical history, physical exam, and vital signs
b. ABCDs, on-going exam, and vital signs
c. Medical history, trauma exam, and vital signs
d. On-going exam, detailed physical exam, and vital signs
Answer: a
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Code 63040 for Laminotomy with decompression of nerve root(s), including partial facetectomy and excision of herniated intervertebral disc, reexploration C1-C2
A) True B) False
You are caring for a 73-year-old female in a nursing home who is experiencing respiratory distress that worsened throughout the night. Currently you find her seated upright in bed with accessory muscle use. Audible rales can be heard; she is diaphoretic and warm to the touch, she has a temperature of 102° F, and her respiratory rate is 32 breaths/min. The patient tells you that her breathing has been getting worse all night. You auscultate the chest and hear rales and rhonchi in all fields of her left lung and rhonchi in her right base, but her right middle and upper lobes sound clear. You determine that this patient is experiencing respiratory distress caused by:
A) Tuberculosis B) Chronic obstructive pulmonary disease C) Congestive heart failure D) Pneumonia