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
Choice A rationale:
Health promotion is the correct concept demonstrated by the nurse. Health promotion refers to activities and strategies that aim to enhance an individual's overall health and well-being. Educating the client with heart disease about the importance of eating a heart-healthy diet is a proactive step towards improving their health.
Choice B rationale:
Holistic health is a broader approach that considers the whole person, including physical, mental, and social aspects. While it is an important concept, the nurse, in this scenario, is primarily focused on educating the client about a specific aspect of their health, which is heart disease management.
Choice C rationale:
Health education is a component of health promotion, but it specifically refers to the process of providing individuals with knowledge and skills to make informed decisions about their health. In this case, the nurse is providing education as a means of promoting the client's health.
Choice D rationale:
Primary prevention involves measures to prevent the development of a disease or condition before it occurs. While promoting a heart-healthy diet is a form of prevention, it does not specifically align with the concept of primary prevention, which typically involves actions taken to avoid the initial occurrence of a health problem.
Correct Answer is B
Explanation
Choice A rationale:
The nurse should not inform the client of the need to pre-pay for the consent of authorization. Precertification for surgery is related to obtaining approval from the client's insurance provider and not about pre-payment.
Choice B rationale:
Contacting the client's insurance carrier to obtain authorization is the correct action to take when obtaining precertification for surgery. Many insurance companies require pre-authorization for surgical procedures to ensure coverage and to confirm that the procedure is medically necessary. This step is essential to prevent financial burdens on the client and ensure they have coverage for the surgery.
Choice C rationale:
Notifying the provider to obtain approval for the surgery is not the nurse's responsibility in the context of precertification. The primary responsibility lies with obtaining approval from the client's insurance carrier.
Choice D rationale:
Witnessing the client sign the surgical consent form is an essential step in the surgical preparation process but is not the same as obtaining precertification. Precertification involves confirming insurance coverage and approval for the surgery, which is the responsibility of the insurance carrier, not the client's consent.
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