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?

Choice A rationale

A risk nursing diagnosis, such as "risk for impaired skin integrity related to inadequate nutrition," identifies a potential problem that does not currently exist but has a high probability of developing if no preventative nursing interventions are implemented. It focuses on the patient's vulnerability to a specific health problem.

Choice B rationale

All nursing diagnoses, including risk diagnoses, require the development of specific nursing interventions aimed at preventing the potential problem from occurring or minimizing its impact. These interventions are crucial for addressing the identified risk factors and promoting patient well-being.

Choice C rationale

Evaluation is a critical component of the nursing process for all nursing diagnoses. The effectiveness of the nursing interventions implemented for a risk diagnosis must be evaluated to determine if they successfully prevented the problem from developing. This ongoing assessment ensures the plan of care is appropriate and achieving the desired outcomes.

Choice D rationale

Nursing diagnoses, including risk diagnoses, are within the scope of nursing practice and guide independent nursing interventions. While collaboration with the medical team is essential for overall patient care, risk diagnoses do not inherently necessitate medical intervention as the primary focus is on preventative nursing actions.

Choice A rationale

While the sibling may have paid for the diagnostic test, this does not grant the nurse the right to access and disclose the results. Patient privacy and confidentiality are paramount, and access to medical records is restricted to those directly involved in the patient's care. Payment for services does not override these privacy regulations.

Choice B rationale

The familial relationship between the nurse and the patient's sibling does not authorize the nurse to access the patient's medical information. Professional boundaries and ethical guidelines prevent healthcare providers from accessing records of family members unless they are directly involved in their care and have a legitimate need-to-know.

Choice C rationale

It is indeed the responsibility of the healthcare provider who ordered the tests or is managing the patient's care to disclose laboratory results and findings directly to the client. This ensures accurate interpretation and appropriate follow-up. Nurses should not bypass this process by independently accessing and sharing results with family members.

Choice D rationale

A nurse-client relationship did not exist between the nurse and the sibling in this scenario. Accessing a patient's medical record requires a legitimate professional need related to the provision of care to that specific patient. Without this established relationship, accessing the sibling's results would be a breach of confidentiality and professional ethics.