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?
Client's skin is pale and diaphoretic
Client reports chest pain after mowing lawn this morning
Client administered nitroglycerin 0.3 mg SL for chest pain
Client's blood pressure is 182/98 mm Hg
The Correct Answer is B
Choice A reason: Client's skin is pale and diaphoretic is not included in the subjective component, but in the objective component. The objective component records the measurable and observable data that the nurse collects from the client, such as vital signs, physical examination findings, and laboratory results.
Choice B reason: Client reports chest pain after mowing lawn this morning is included in the subjective component. The subjective component records the data that the client verbalizes or expresses, such as symptoms, feelings, preferences, and beliefs.
Choice C reason: Client administered nitroglycerin 0.3 mg SL for chest pain is not included in the subjective component, but in the plan component. The plan component records the interventions and actions that the nurse implements or plans to implement for the client, such as medications, treatments, referrals, and education.
Choice D reason: Client's blood pressure is 182/98 mm Hg is not included in the subjective component, but in the objective component. The objective component records the measurable and observable data that the nurse collects from the client, such as vital signs, physical examination findings, and laboratory results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The prodromal stage is the period between the exposure to the infectious agent and the onset of specific symptoms. During this stage, the person may experience mild and nonspecific signs of infection, such as fatigue or lowgrade fever. The client in the question has already developed specific symptoms of infection, such as sneezing, productive cough, and fever, which indicate that they have passed the prodromal stage.
Choice B reason: The period of convalescence is the stage of recovery after the infection. During this stage, the person's symptoms gradually subside, and their immune system eliminates the infectious agent from the body. The client in the question is still experiencing symptoms of infection, which suggest that they have not reached the period of convalescence yet.
Choice C reason: The acute illness stage is the peak of the infection, when the person exhibits the most severe and specific symptoms of the disease. During this stage, the person's immune system fights against the infectious agent, and the outcome of the infection is determined. The client in the question is likely in the acute illness stage, as they have been experiencing symptoms of infection for 4 days, and their condition has worsened over time.
Choice D reason: The incubation stage is the time between the entry of the infectious agent into the body and the appearance of the first symptoms of infection. During this stage, the person does not feel ill, but the infectious agent is multiplying in the body. The client in the question has already developed symptoms of infection, which indicate that they have left the incubation stage.
Correct Answer is A
Explanation
Choice A reason: Evidence based practice is the process that the nurse is planning to use. Evidence based practice is the integration of the best available evidence from research, clinical expertise, and patient preferences to make decisions and provide quality care for the client.
Choice B reason: Standardization is not the process that the nurse is planning to use. Standardization is the process of establishing and implementing uniform criteria, methods, or procedures for a specific activity or task. Standardization can help improve efficiency, consistency, and safety, but it does not necessarily involve research or scientific data.
Choice C reason: Benchmarking is not the process that the nurse is planning to use. Benchmarking is the process of comparing the performance, outcomes, or practices of one's own organization or unit with those of other organizations or units that are recognized as leaders or exemplars in the same field. Benchmarking can help identify gaps, strengths, and areas for improvement, but it does not necessarily involve research or scientific data.
Choice D reason: Root cause analysis is not the process that the nurse is planning to use. Root cause analysis is the process of identifying and analyzing the underlying factors or causes that contribute to an adverse event or error. Root cause analysis can help prevent recurrence, enhance safety, and promote learning, but it does not necessarily involve research or scientific data.
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