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 A
Explanation
Choice A: This is the correct answer. An electronic health record (EHR) is a digital version of a client's medical history and other health information that can be accessed by authorized providers and the client. A personal health record (PHR) is a subset of an EHR that allows the client to view and manage their own health information, such as medications, allergies, test results, and appointments. A PHR can enhance the client's satisfaction, engagement, and empowerment in their health care.
Choice B: This is incorrect. Provides providers client information to track for research studies is not a benefit of an electronic health record, but a potential use of it. EHRs can facilitate health research by providing large and diverse data sets that can be analyzed for various purposes, such as clinical trials, epidemiology, and quality improvement. However, this use of EHRs must comply with ethical and legal standards, such as informed consent, privacy, and confidentiality.
Choice C: This is incorrect. Grants significant other access to client information is not a benefit of an electronic health record, but a matter of the client's preference and consent. EHRs must protect the client's privacy and confidentiality rights, and only disclose their information to authorized parties, such as health care providers, insurers, or public health agencies. The client can choose to share their information with their significant other or anyone else, but they must give explicit permission to do so.
Choice D: This is incorrect. Coordinates all healthcare client has received into one platform is not a benefit of an electronic health record, but a goal of it. EHRs aim to improve the coordination and continuity of care by allowing multiple providers to access and update the same information, enabling real-time collaboration, and providing decision support tools. However, this goal is not fully achieved yet, as there are still challenges and barriers to the interoperability and integration of EHRs across different settings and systems.
Correct Answer is C
Explanation
Choice A reason: Irrigating and performing a dressing change for a client who has a pressure injury wound is not a task that the nurse should delegate to an AP. This task requires the nurse's clinical judgment, skill, and knowledge to assess the wound, select the appropriate dressing, and prevent infection. This task is also within the nurse's scope of practice, but not the AP's scope of practice.
Choice B reason: Administering oral PRN pain medication to a client who has arthritis is not a task that the nurse should delegate to an AP. This task involves the nurse's responsibility to evaluate the client's pain level, determine the need and the dosage of the medication, and monitor the client's response and side effects. This task is also within the nurse's scope of practice, but not the AP's scope of practice.
Choice C reason: Obtaining a daily weight on a client who has heart failure is a task that the nurse can delegate to an AP. This task is a routine and standardized procedure that does not require the nurse's clinical judgment, skill, or knowledge. This task is also within the AP's scope of practice, if the nurse provides clear directions and supervision.
Choice D reason: Reinforcing teaching the use of an incentive spirometer to a postoperative client is not a task that the nurse should delegate to an AP. This task involves the nurse's role to educate the client about the purpose, benefits, and technique of using the incentive spirometer, and to evaluate the client's understanding and compliance. This task is also within the nurse's scope of practice, but not the AP's scope of practice.
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