NR548 VERIFIED WEEK 4 EXAM QUESTIONS AND
ANSWERS
Chief Complaint
the primary problem that prompted the client to schedule a visit.
Use the client's own words.
History of Present Illness
is a concise, clear, and chronological description of the chief complaint which prompted
the client's visit. A symptom analysis guided by the mnemonic "OLDCARTS" will reveal
information regarding the onset, location, duration, characteristics, aggravating factors,
relieving factors, treatments, and severity of the symptoms.
Pertinent positives
symptoms that are expected with a potential diagnosis related to the chief complaint.
Pertinent negatives
symptoms the client does not have that are expected with a potential diagnosis related
to the chief complaint.
OLDCARTS
onset, location, duration, characteristics, aggravating factors, relieving factors,
treatments, and severity of the symptoms.
Onset
"When did this start?"
Location
"Where did the problem start; does it move anywhere?"
Duration
"How long does the problem last or is it constant?"
Characteristics
"Can you describe what the problem feels like?"
Aggravating Factors
"Does anything make it worse?"
Relieving Factors
"Does anything make it better?"
Treatments
, "Have you taken any medications or nonpharmaceutical treatments for this problem?"
Severity of the Symptoms
"How bothersome is this problem?"
Childhood Illnesses
Inquire about childhood illnesses such as measles, chickenpox, or scarlet fever and
chronic childhood illnesses such as diabetes or asthma.
Adult Illnesses
Inquire about illnesses such as diabetes, hypertension, or asthma and hospitalizations.
Surgical
Document dates, indications, and types of surgical procedures.
Obstetric/Gynecologic
Document number of pregnancies (gravida), number of deliveries (para-term, preterm,
abortions, and living children), menstrual history, methods of contraception, and sexual
function.
Psychiatric
Document diagnoses, hospitalizations, treatments, and the time frame.
Health Maintenance
Document immunizations and screening tests such as pap smears, mammograms, or
colonoscopies. Include the results and dates of screening tests.
The Psychiatric History
Have you ever been hospitalized for any mental health 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?
Documentation of History of Present Illness
should include an opening statement, a characterization of the chief complaint in
chronological order, pertinent positive symptoms, pertinent negative symptoms, and
other relevant information from the history.
family history
Document information about the client's parents, grandparents, siblings, children, and
grandchildren regarding their age, health, and cause of death. Include whether they
ANSWERS
Chief Complaint
the primary problem that prompted the client to schedule a visit.
Use the client's own words.
History of Present Illness
is a concise, clear, and chronological description of the chief complaint which prompted
the client's visit. A symptom analysis guided by the mnemonic "OLDCARTS" will reveal
information regarding the onset, location, duration, characteristics, aggravating factors,
relieving factors, treatments, and severity of the symptoms.
Pertinent positives
symptoms that are expected with a potential diagnosis related to the chief complaint.
Pertinent negatives
symptoms the client does not have that are expected with a potential diagnosis related
to the chief complaint.
OLDCARTS
onset, location, duration, characteristics, aggravating factors, relieving factors,
treatments, and severity of the symptoms.
Onset
"When did this start?"
Location
"Where did the problem start; does it move anywhere?"
Duration
"How long does the problem last or is it constant?"
Characteristics
"Can you describe what the problem feels like?"
Aggravating Factors
"Does anything make it worse?"
Relieving Factors
"Does anything make it better?"
Treatments
, "Have you taken any medications or nonpharmaceutical treatments for this problem?"
Severity of the Symptoms
"How bothersome is this problem?"
Childhood Illnesses
Inquire about childhood illnesses such as measles, chickenpox, or scarlet fever and
chronic childhood illnesses such as diabetes or asthma.
Adult Illnesses
Inquire about illnesses such as diabetes, hypertension, or asthma and hospitalizations.
Surgical
Document dates, indications, and types of surgical procedures.
Obstetric/Gynecologic
Document number of pregnancies (gravida), number of deliveries (para-term, preterm,
abortions, and living children), menstrual history, methods of contraception, and sexual
function.
Psychiatric
Document diagnoses, hospitalizations, treatments, and the time frame.
Health Maintenance
Document immunizations and screening tests such as pap smears, mammograms, or
colonoscopies. Include the results and dates of screening tests.
The Psychiatric History
Have you ever been hospitalized for any mental health 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?
Documentation of History of Present Illness
should include an opening statement, a characterization of the chief complaint in
chronological order, pertinent positive symptoms, pertinent negative symptoms, and
other relevant information from the history.
family history
Document information about the client's parents, grandparents, siblings, children, and
grandchildren regarding their age, health, and cause of death. Include whether they
