Exhibits

Review the electronic health record. Which finding(s) should the nurse identify as subjective data? Select all that apply.

A. A client who is reporting a severe headache and new vision changes: Sudden severe headache with vision changes may indicate a potentially life-threatening condition such as a stroke, aneurysm, or increased intracranial pressure. This client requires an immediate emergency assessment to prevent serious complications.

B. A client who requires assistance when transferring to the exam table: Needing help with transfers is important for safety but does not indicate an urgent medical condition. This task can be addressed after more critical clients are assessed.

C. A client who requires a follow-up physical for their medication refill: Routine follow-up for prescription refills is non-urgent and can safely be scheduled after emergency or acute cases are addressed.

D. A client who is reporting minor swelling and pain in their left foot: Minor swelling and pain are usually non-life-threatening. While assessment is necessary, it does not require immediate emergency evaluation compared to acute neurological or vision changes.

A. Subjective: "The client seems happy today." Objective: "Vital signs within normal limits.": The subjective statement is based on the nurse’s interpretation rather than the client’s own report, making it less accurate. Objective data is appropriate, but the subjective portion is not precise.

B. Assessment: "Client is anxious." Plan: "Give client medication as needed.": The assessment labels the client’s emotional state without including supporting data, which is not consistent with SOAP note standards that require evidence-based observations.

C. Assessment: "Client is noncompliant with medications." Plan: "Assess for medication side effects.": Labeling the client as noncompliant is judgmental and does not reflect actual assessment data. Objective or subjective evidence supporting this statement is needed.

D. Subjective: "The client reports pain in the right leg." Objective: "Right leg appears swollen and red.": This example accurately differentiates subjective data (client’s own report) from objective data (observable and measurable findings), representing proper SOAP note documentation.