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.
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Related Questions
Correct Answer is ["B"]
Explanation
a. Using medical jargon
- Rationale: Medical jargon can be precise and efficient for communication among healthcare professionals. However, it can be confusing and intimidating for patients or non-medical staff, which is not therapeutic.
b. Active listening
- Rationale: Active listening involves fully focusing, understanding, responding and then remembering what is being said. It is a fundamental component of therapeutic communication as it shows respect and understanding for the speaker, builds trust, and helps to facilitate a deeper understanding of a patient’s perspective and needs.
c. Giving advice
- Rationale: While it might seem helpful to give advice, it can often disempower the patient or make them feel like they are not being heard. Therapeutic communication should be patient-centered and empowering.
d. Using closed-ended questions
- Rationale: Closed-ended questions can be useful for gathering specific information quickly. However, they limit the depth of response and can shut down communication, making them less therapeutic.
The correct answer isb. Active listening. This technique is a key component of therapeutic communication as it encourages a deeper understanding and is respectful and patient-centered. It helps in building a therapeutic nurse-patient relationship.
Correct Answer is B
Explanation
Choice A rationale:
The novice-to-expert model for nursing competence includes several stages, and the "novice" stage represents a beginner who has limited experience and lacks clinical support. This stage typically involves individuals who are just starting their nursing careers and are in the early phases of learning.
Choice B rationale:
An "advanced beginner" is the next stage in the novice-to-expert model. This stage is characterized by individuals who have gained some experience and can perform tasks with increased competence. However, they still require clinical support and guidance in certain situations. It's a transitional phase between complete novice and more proficient levels of competence.
Choice C rationale:
The "proficient" stage in the model represents nurses who have acquired a higher level of competence and are capable of handling a wide range of situations. They do not require the same level of clinical support as those in the advanced beginner stage.
Choice D rationale:
The "competent" stage represents nurses who have reached a high level of competence and can function effectively in most situations without continuous clinical support. They are highly skilled and experienced in their practice.
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