Cardiac-Vascular Nursing (CVRN) Practice Exam

Where should the cardiac-vascular nurse document a patient's positive calcium score?

1. Past medical history

2. Personal/social history

3. Presenting problem

4. Review of symptoms

The correct answer is: Presenting problem

The correct location for documenting a patient's positive calcium score is in the section pertaining to the presenting problem. This is because the calcium score is a significant finding that directly relates to the patient's cardiovascular health and is integral to their current evaluation. Documenting it under the presenting problem helps to contextualize the score in relation to the symptoms or conditions that prompted the patient's visit or assessment. In clinical documentation, the presenting problem section captures key details that are immediately relevant to the patient's current health status and informs necessary interventions or diagnostic approaches. A positive calcium score is indicative of potential coronary artery disease risk and should be highlighted in this context to ensure proper continuity of care, assessment of risk factors, and addressing any immediate concerns. Additionally, while documenting in past medical history might seem relevant, a calcium score reflects a recent status of cardiovascular health rather than historical health data. Personal or social history typically pertains to factors such as lifestyle choices or family backgrounds, while the review of symptoms focuses on reported symptoms rather than specific diagnostic results.