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 reports chest pain after mowing lawn this morning.
Client's blood pressure is 182/98 mm Hg.
Client administered nitroglycerin 0.3 mg SL for chest pain.
Client's skin is pale and diaphoretic.
The Correct Answer is A
Choice A rationale:
In the SOAP charting model, the subjective component is where the client's subjective information and feelings are documented. This includes the client's own reports of symptoms, sensations, and experiences. In this case, the client reporting chest pain after mowing the lawn this morning is a subjective statement made by the client. This information is valuable as it provides insight into the client's perception of their condition and helps healthcare providers understand their symptoms and experiences.
Choice B rationale:
The blood pressure reading (182/98 mm Hg) is an objective measurement, not a subjective statement from the client. Objective data includes measurable and observable information, like vital signs, lab results, and physical examination findings. This type of information is typically documented in the objective component of SOAP charting.
Choice C rationale:
The administration of nitroglycerin (0.3 mg SL) is also an objective action taken by the client, not a subjective statement. It falls under the plan section of the SOAP chart, where healthcare providers outline the actions or interventions taken.
Choice D rationale:
The description of the client's skin (pale and diaphoretic) is also objective data. It represents observable physical signs and is not part of the subjective component, which focuses on the client's own statements and feelings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Using a cell phone to request assistance from the client's room ensures timely communication and enhances patient care. Quick access to help can be vital in emergency situations, ensuring prompt and effective intervention.
Choice B rationale: Sending a personal text to a co-worker during work hours is unprofessional and can lead to distractions. It can compromise patient care and violates workplace policies on personal device usage, ensuring focus remains on patient safety and care.
Choice C rationale: Calling the client's family member per their request can violate privacy and confidentiality regulations, such as HIPAA in the US. Communication with family should go through proper channels to ensure compliance with legal and ethical standards.
Choice D rationale: Taking a photo of a client's incision site for learning purposes without proper consent and documentation breaches patient confidentiality and privacy. It could also result in legal ramifications and violates institutional policies on using personal devices for work-related tasks.
Correct Answer is A
Explanation
This question evaluates communication adaptations for clients experiencing hearing impairment. The nurse must apply therapeutic communication principles that maximize auditory perception and minimize environmental interference. Knowledge of sensory deficits, lip-reading facilitation, sound discrimination, and appropriate assistive communication strategies is required to identify the safest intervention.
Choice A rationale: Reducing competing environmental sounds improves speech discrimination and auditory processing in hearing-impaired clients. Background noise interferes with interpretation of consonants and speech frequencies. Quiet environments enhance comprehension, decrease communication fatigue, and promote accurate understanding of discharge instructions and healthcare information.
Choice B rationale: Braille communication assists clients with severe visual impairment, not hearing impairment. Hearing loss primarily affects auditory sensory pathways involving cochlear hair cells or auditory nerve transmission. Providing Braille would not improve comprehension unless the client additionally has blindness or significant visual disability.
Choice C rationale: Standing directly beside the client limits visibility of facial expressions and lip movements essential for speech interpretation. Effective communication with hearing-impaired individuals requires face-to-face positioning, adequate lighting, and clear articulation to support residual hearing and visual speech cues simultaneously.
Choice D rationale: Repeating misunderstood phrases identically often fails because the original wording remains difficult to discriminate acoustically. Rephrasing sentences with different vocabulary improves semantic processing and contextual interpretation. Therapeutic communication emphasizes clarification rather than repetitive unchanged verbalization during hearing-related misunderstandings.
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