A nurse is documenting client care including only unexpected findings related to the client's condition.
Which of the following documentation methods is the nurse utilizing?

Charting by exception (CBE).

Focus charting (DAR).

Problem-oriented medical record (POMR).

SOAP documentation.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Charting by exception (CBE) is a documentation method in which the nurse documents only unexpected findings or significant deviations from the client's normal condition. It is based on the assumption that the client's baseline status remains within the expected range, and deviations from this norm are documented. CBE is efficient and allows nurses to focus on relevant and critical information, reducing unnecessary documentation. It is particularly useful in clinical settings where frequent assessments are needed.

Choice B rationale:

Focus charting (DAR) is another method of documenting client care that emphasizes a structured approach to documentation, with a focus on data, action, and response (DAR). While it provides a systematic way to document care, it does not necessarily limit documentation to only unexpected findings. Focus charting encourages documentation of care in a problem-oriented manner, which may include expected or routine assessments.

Choice C rationale:

Problem-oriented medical record (POMR) is a documentation system that focuses on organizing client information around specific healthcare problems or diagnoses. It encourages a problem-solving approach to care and promotes the inclusion of a comprehensive client history and care plan. POMR documentation may involve both expected and unexpected findings, so it does not limit documentation to only unexpected findings.

Choice D rationale:

SOAP documentation stands for Subjective, Objective, Assessment, and Plan. It is a structured method of documenting healthcare encounters. SOAP notes include a wide range of information, including both subjective (patient's description of symptoms) and objective (clinician's observations) data. While SOAP notes are organized, they do not specifically limit documentation to only unexpected findings.

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Correct Answer is A

Explanation

Choice A rationale:

Health promotion is the correct concept demonstrated by the nurse. Health promotion refers to activities and strategies that aim to enhance an individual's overall health and well-being. Educating the client with heart disease about the importance of eating a heart-healthy diet is a proactive step towards improving their health.

Choice B rationale:

Holistic health is a broader approach that considers the whole person, including physical, mental, and social aspects. While it is an important concept, the nurse, in this scenario, is primarily focused on educating the client about a specific aspect of their health, which is heart disease management.

Choice C rationale:

Health education is a component of health promotion, but it specifically refers to the process of providing individuals with knowledge and skills to make informed decisions about their health. In this case, the nurse is providing education as a means of promoting the client's health.

Choice D rationale:

Primary prevention involves measures to prevent the development of a disease or condition before it occurs. While promoting a heart-healthy diet is a form of prevention, it does not specifically align with the concept of primary prevention, which typically involves actions taken to avoid the initial occurrence of a health problem.

A. Client reports chest pain after mowing lawn this morning. B. Client's blood pressure is 182/98 mm Hg. C. Client administered nitroglycerin 0.3 mg SL for chest pain. D. Client's skin is pale and diaphoretic.

Correct Answer is A

Explanation

Choice A rationale:

In the SOAP charting model, the subjective component is where the client's subjective information and feelings are documented. This includes the client's own reports of symptoms, sensations, and experiences. In this case, the client reporting chest pain after mowing the lawn this morning is a subjective statement made by the client. This information is valuable as it provides insight into the client's perception of their condition and helps healthcare providers understand their symptoms and experiences.

Choice B rationale:

The blood pressure reading (182/98 mm Hg) is an objective measurement, not a subjective statement from the client. Objective data includes measurable and observable information, like vital signs, lab results, and physical examination findings. This type of information is typically documented in the objective component of SOAP charting.

Choice C rationale:

The administration of nitroglycerin (0.3 mg SL) is also an objective action taken by the client, not a subjective statement. It falls under the plan section of the SOAP chart, where healthcare providers outline the actions or interventions taken.

Choice D rationale:

The description of the client's skin (pale and diaphoretic) is also objective data. It represents observable physical signs and is not part of the subjective component, which focuses on the client's own statements and feelings.

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A nurse is documenting client care including only unexpected findings related to the client's condition.Which of the following documentation methods is the nurse utilizing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is instructing a client who has heart disease about ways to improve their health such as eating a heart-healthy diet.Which of the following concepts is the nurse demonstrating to the client?

Correct Answer is A

Explanation

A nurse is documenting in a client's health record using the subjective, objective, assessment, and plan (SOAP) charting model.Which of the following information should be included in the subjective component?

Correct Answer is A

Explanation

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A nurse is documenting client care including only unexpected findings related to the client's condition.
Which of the following documentation methods is the nurse utilizing?