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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?

A.

Client reports chest pain after mowing lawn this morning.

B.

Client's blood pressure is 182/98 mm Hg.

C.

Client administered nitroglycerin 0.3 mg SL for chest pain.

D.

Client's skin is pale and diaphoretic.

Answer and Explanation

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.


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Related Questions

Correct Answer is ["A","B","C","D"]

Explanation

Findings that Could Increase Susceptibility to Infection:

  1. Budesonide 6 mg PO daily:

    • Explanation: Budesonide is a corticosteroid used to reduce inflammation, often prescribed for conditions like Crohn's disease. While it helps manage inflammation, corticosteroids also suppress the immune system. This immunosuppressive effect can increase the client's susceptibility to infections.

  2. BMI of 16:

    • Explanation: A BMI of 16 is considered underweight. Malnutrition or being underweight can weaken the immune system, making a person more susceptible to infections because their body lacks the necessary nutrients and energy to support immune function.

  3. History of Type 2 Diabetes Mellitus:

    • Explanation: Diabetes, particularly if not well-controlled, can impair the immune system and increase the risk of infections. High blood sugar levels can hinder the function of immune cells, making it easier for infections to develop and harder for the body to fight them.

  4. New Diagnosis of Crohn's Disease:

    • Explanation: Crohn's disease is an inflammatory bowel disease that causes inflammation of the digestive tract. This chronic inflammation can affect the body's ability to absorb nutrients, leading to nutritional deficiencies that impair the immune system. Additionally, the disease itself, especially when active, can increase the risk of infection.

Findings That Do Not Increase Susceptibility to Infection:

  1. Hematocrit (Hct) of 47%:

    • Explanation: The Hct level is within the normal range of 37% to 52%. It measures the percentage of red blood cells in the blood. Since it's normal, it does not indicate an increased risk of infection.

  2. Hemoglobin (Hgb) of 16 g/dL:

    • Explanation: The Hgb level is also within the normal range of 12 to 18 g/dL. Hemoglobin is a protein in red blood cells that carries oxygen. This normal level does not suggest a higher risk of infection.

  3. Potassium level of 3.6 mEq/L:

    • Explanation: Potassium levels are within the normal range of 3.5 to 5.0 mEq/L. This electrolyte level is unrelated to infection risk in the context provided.

Correct Answer is D

Explanation

Choice A rationale:

There are actually five rights of delegation: right task, right circumstance, right person, right direction/communication, and right supervision/evaluation. This statement is not accurate.

Choice B rationale:

It is not the duty of the delegatee to perform a task without asking questions. Effective delegation involves clear communication, including the opportunity for the delegatee to ask questions and seek clarification as needed.

Choice C rationale:

While the nurse manager plays a role in delegation, the responsibility for delegation does not solely rest on the nurse manager. Delegation is a shared responsibility among all nurses, and the person delegating the task must ensure it is appropriate and clear.

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