Exam (elaborations)
2024 NR548 WEEK 4 EXAM WITH CORRECT ANSWERS
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2024 NR548 WEEK 4 EXAM WITH CORRECT ANSWERS
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NR548 Week 4Study online at https://quizlet.com/_ccehas
1. Chief Complaint the primary problem that prompted the client to schedule
a visit.
Use the client's own words.
2. History of Pre- is a concise, clear, and chronological description of the
sent Illness chief complaint which prompted the client's visit. A symp-
tom analysis guided by the mnemonic "OLDCARTS" will
reveal information regarding the onset, location, dura-
tion, characteristics, aggravating factors, relieving factors,
treatments, and severity of the symptoms.
3. Pertinent posi- symptoms that are expected with a potential diagnosis
tives related to the chief complaint.
4. Pertinent nega- symptoms the client does not have that are expected with
tives a potential diagnosis related to the chief complaint.
5. OLDCARTS onset, location, duration, characteristics, aggravating fac-
tors, relieving factors, treatments, and severity of the
symptoms.
6. Onset "When did this start?"
7. Location "Where did the problem start; does it move anywhere?"
8. Duration "How long does the problem last or is it constant?"
9. Characteristics "Can you describe what the problem feels like?"
10. Aggravating Fac- "Does anything make it worse?"
tors
11. Relieving Fac- "Does anything make it better?"
tors
12. Treatments "Have you taken any medications or nonpharmaceutical
treatments for this problem?"
13. Severity of the "How bothersome is this problem?"
Symptoms
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, NR548 Week 4
Study online at https://quizlet.com/_ccehas
14. Childhood Ill- Inquire about childhood illnesses such as measles, chick-
nesses enpox, or scarlet fever and chronic childhood illnesses
such as diabetes or asthma.
15. Adult Illnesses Inquire about illnesses such as diabetes, hypertension, or
asthma and hospitalizations.
16. Surgical Document dates, indications, and types of surgical proce-
dures.
17. Obstetric/Gyne- Document number of pregnancies (gravida), number of
cologic deliveries (para-term, preterm, abortions, and living chil-
dren), menstrual history, methods of contraception, and
sexual function.
18. Psychiatric Document diagnoses, hospitalizations, treatments, and
the time frame.
19. Health Mainte- Document immunizations and screening tests such as
nance pap smears, mammograms, or colonoscopies. Include the
results and dates of screening tests.
20. The Psychiatric Have you ever been hospitalized for any mental health
History issues?
Have you ever had counseling or psychotherapy?
Have you ever taken medications for your mental health in
the past?
Are you currently on any medications for mental health or
sleep?
21. Documentation should include an opening statement, a characterization of
of History of the chief complaint in chronological order, pertinent pos-
Present Illness itive symptoms, pertinent negative symptoms, and other
relevant information from the history.
22. family history Document information about the client's parents, grand-
parents, siblings, children, and grandchildren regarding
their age, health, and cause of death. Include whether they
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