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 B
Explanation
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.
Correct Answer is B
Explanation
Choice A reason: This statement is incorrect because a nurse cannot access the records of any client in the healthcare facility, unless they have a legitimate need to do so. Accessing the records of clients who are not under their care is a violation of the client's privacy and confidentiality, and may result in legal or disciplinary actions.
Choice B reason: This statement is correct because a nurse can only access the records of clients they are actively caring for, as part of their professional duty and responsibility. Accessing the records of clients they are caring for is necessary to provide safe and effective care, and to communicate with other members of the healthcare team.
Choice C reason: This statement is incorrect because a nurse cannot share information from the client’s medical record with immediate family members, unless the client has given consent, or the disclosure is authorized by law. Sharing information from the client's medical record with family members without the client's permission is a breach of the client's privacy and confidentiality, and may cause harm or distress to the client or the family.
Choice D reason: This statement is incorrect because a nurse cannot share information about a client with clients who have a similar diagnosis, unless the client has given consent or the disclosure is authorized by law. Sharing information about a client with other clients without the client's permission is a breach of the client's privacy and confidentiality, and may compromise the client's dignity or safety.
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