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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","F"]
Explanation
Choice A reason: Quality education is a value that is part of the NSNA code of ethics. According to the NSNA Core Values and Interpretative Statements, quality education is an act or process of imparting or acquiring general knowledge, developing the powers of reasoning and judgment, and generally of preparing oneself or others intellectually for a profession. NSNA informs, prepares, and inspires members to develop continuous, lifelong learning and ethics of the profession.
Choice B reason: Safety is not a value that is part of the NSNA code of ethics, but a responsibility that is part of the NSNA Code of Academic and Clinical Conduct. According to this code, nursing students have a responsibility to promote the safety of clients, self, and others in academic and clinical settings. Safety is also a core value of nursing practice, but it is not explicitly stated in the NSNA code of ethics.
Choice C reason: Diversity is not a value that is part of the NSNA code of ethics, but a goal that is part of the NSNA Mission Statement. According to this statement, NSNA is committed to fostering the professional development of nursing students with a focus on diversity and inclusion. Diversity is also a principle that guides the NSNA Code of Professional Conduct, which states that nursing students should respect the diversity of clients, colleagues, faculty, and staff.
Choice D reason: Professionalism is a value that is part of the NSNA code of ethics. According to the NSNA Core Values and Interpretative Statements, professionalism is the characteristics that describe an individual striving to maintain the highest standards for one’s chosen path – honesty, integrity, responsibility and conducting oneself with responsibility, integrity, accountability, and excellence. As NSNA members, it is important to create a culture of professionalism in our organization and to uphold the values of professionalism in order to conduct ourselves and our organization in the most respectful, honest way.
Choice E reason: Advocacy is a value that is part of the NSNA code of ethics. According to the NSNA Core Values and Interpretative Statements, advocacy is an activity or process to work on behalf of self and/or others to raise awareness of a concern and to promote solutions to the issue. The nursing profession is based on advocating for patients and families in order to help facilitate the healing process; NSNA serves as an advocate for nursing students by representing them as one united voice.
Choice F reason: Confidentiality is a value that is part of the NSNA code of ethics. According to the NSNA Code of Professional Conduct, nursing students should protect the privacy and confidentiality of clients, colleagues, faculty, and staff. Confidentiality is also a principle that guides the NSNA Code of Academic and Clinical Conduct, which states that nursing students should maintain client confidentiality in verbal, written, and electronic forms.
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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