A nurse is documenting in a client's information using the subjective, objective, assessment, and plan (SOAP) charting model.
Which of the following should be included in the subjective data?
Client administered nitroglycerin.
Client reports chest pain after mowing the lawn this morning.
Client's blood pressure is 182/98 mmHg.
Client's skin is pale and diaphoretic.
The Correct Answer is B
Choice A rationale
Client administered nitroglycerin is objective data because it is a documented action performed by the client and can be verified. Subjective data, on the other hand, comes from the client's perspective.
Choice B rationale
Client reports chest pain after mowing the lawn this morning is subjective data because it is a statement made by the client about their experience. It describes their feelings and circumstances as they perceive them.
Choice C rationale
Client's blood pressure is 182/98 mmHg is objective data because it is a measurable physiological parameter obtained through assessment. It is a factual finding that can be directly observed and recorded.
Choice D rationale
Client's skin is pale and diaphoretic is objective data because these are observable physical signs noted by the nurse during assessment. They are factual descriptions of the client's physical condition.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Providing additional written instructions is a helpful teaching strategy but does not directly demonstrate the patient's ability to self-administer the injection correctly. It addresses the teaching method, not the outcome of the teaching.
Choice B rationale
The patient denying concerns does not necessarily indicate successful learning. The patient might have unexpressed concerns or may not fully understand the procedure despite verbalizing otherwise. This statement reflects the patient's verbalization, not their demonstrated skill.
Choice C rationale
The patient correctly self-administering their next scheduled dose of insulin is the most direct and reliable evidence that the teaching was successful. It demonstrates that the patient has acquired the necessary knowledge and skills to perform the injection safely and accurately in a real-life situation.
Choice D rationale
Identifying the steps and equipment used indicates that the patient has some understanding of the procedure. However, it does not guarantee that they can perform the injection correctly. Practical demonstration is required to confirm successful learning of a psychomotor skill.
Correct Answer is B
Explanation
Choice A rationale
A medical diagnosis identifies a specific disease or pathological process based on signs, symptoms, diagnostic tests, and medical history. It focuses on the disease itself and its etiology, which differs from evaluating a patient's response to health issues.
Choice B rationale
A nursing diagnosis is a clinical judgment concerning a human response to health conditions, life processes, or vulnerability for that response by an individual, family, group, or community. It provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.
Choice C rationale
A collaborative problem is a potential or actual physiological complication that nurses monitor to detect the onset of changes in a patient’s status. These problems require both nurse-prescribed and physician-prescribed interventions, focusing on managing potential complications rather than the response itself.
Choice D rationale
A physician's order is a directive from a medical doctor or other legally recognized healthcare provider that outlines specific treatments, medications, tests, or other interventions for a patient. It guides medical care, not the identification of patient responses.
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