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?

Choice A reason: Providing competencies for the nurses to achieve before licensure is not a description of standards of practice, but rather a function of the nursing education and accreditation system. Standards of practice are authoritative statements that define the expected level of performance for nurses after they obtain their license.

Choice B reason: Establishing a protocol for care to provide for a specific health problem is not a description of standards of practice, but rather a function of the clinical practice guidelines and evidence based practice. Standards of practice are broader and more general statements that apply to all nurses regardless of their specialty or setting.

Choice C reason: Specifying that nurses provide care that reflects current and competent level of behavior when providing client care is a description of standards of practice, as it captures the essence of what standards of practice are and why they are important. Standards of practice are based on the best available evidence and professional consensus, and they guide nurses in delivering safe, quality, and ethical care to their clients.

Choice D reason: Listing a set of skills that all nurses should be competent in performing, outlining responsibilities that every nurse is expected to provide regardless of their role is not a description of standards of practice, but rather a function of the scope of practice. Scope of practice describes the services that a qualified health professional is deemed competent to perform, and permitted to undertake, in keeping with the terms of their professional license..

Choice A reason: Obtaining a detailed history is the first action that the nurse should take. History can help the nurse determine the cause, frequency, and severity of the bruises, as well as the child's relationship with the abuser and the risk of further harm. History can also help the nurse assess the child's physical and emotional state, and provide evidence for reporting the abuse later.
Choice B reason: Reporting the suspected abuse to the authorities is not the first action that the nurse should take. The nurse should report the abuse only after obtaining a history and confirming the suspicion. Reporting the abuse prematurely can jeopardize the child's safety and the nurse's credibility. The nurse should also follow the legal and ethical guidelines for reporting abuse in their jurisdiction.
Choice C reason: Requesting a social services referral is not the first action that the nurse should take. The nurse should request a social services referral only after reporting the abuse and ensuring the child's protection. A social services referral can help the child access resources and support, such as counseling, legal aid, foster care, etc. The nurse should also collaborate with the social worker and other members of the interdisciplinary team to provide holistic care for the child.
Choice D reason: Telling the child what will happen to her when the abuse is reported is not the first action that the nurse should take. The nurse should tell the child what will happen to her only after obtaining a history and reporting the abuse. The nurse should also use age-appropriate language and reassure the child that the abuse is not her fault and that she is not alone. The nurse should avoid making promises that they cannot keep, such as saying that the abuser will never hurt her again.