The nurse reviews the providers notes that are written in the SOAP format.
Which entry represents the "P" portion of the note?
Walked 350 foot unassisted with steady gait.
Bilateral lower extremities have full ROM with intact reflexes.
nsult with discharge planning on discharge home in 3 days.
The Correct Answer is A
Choice A rationale:
In the SOAP format used for medical documentation, "P" stands for Plan. The "P" portion of the note includes the healthcare provider's plan for the patient, which may involve treatments, medications, or other interventions. Option A discusses the patient's ability to walk unassisted, feelings of safety while ambulating, and plans for discharge home in 3 days. This information represents the provider's plan for the patient's care and fits the "P" portion of the SOAP note.
Choice B rationale:
Option B describes the patient's physical examination findings related to range of motion and reflexes in the lower extremities. This information falls under the "Objective" section of the SOAP note, which includes observable and measurable data. While important for the overall patient assessment, it does not represent the provider's plan for the patient's care (the "P" portion of SOAP).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Telling the patient that their wife will be fine does not address the patient's concerns and may come across as dismissive. It does not encourage further communication about the patient's fears and worries.
Choice B rationale:
Dismissing the patient's concerns and instructing them to sleep does not address the underlying issue. It fails to acknowledge the patient's emotional distress and may make the patient feel unheard and unsupported.
Choice C rationale:
Offering medication without exploring the patient's concerns further does not address the root cause of the patient's anxiety. It is important to assess the patient's emotional state and concerns before resorting to medication.
Choice D rationale:
Asking the patient, "What seems to be concerning you the most?" demonstrates active listening and empathy. It encourages the patient to express their feelings and fears, allowing the nurse to provide appropriate emotional support and interventions. Open-ended questions like this facilitate therapeutic communication and help establish trust between the nurse and the patient.
Correct Answer is ["C","D"]
Explanation
Choice A rationale:
The nurse verifies the recipient's fax number before faxing private patient information. This action is appropriate and ensures that patient information is sent to the correct recipient, maintaining patient confidentiality and privacy. Verifying recipient information is a standard practice in healthcare settings to prevent data breaches.
Choice B rationale:
The nurse documents the patient assessment using objective data. This action is appropriate and follows evidence-based practice guidelines. Objective data are measurable and observable, providing a clear picture of the patient's condition. Objective documentation enhances communication among healthcare providers and ensures accurate representation of the patient's status.
Choice C rationale:
The nurse posts the obituary of a patient on social media. This action is highly inappropriate and unethical. It breaches patient confidentiality and privacy, violating the Health Insurance Portability and Accountability Act (HIPAA) regulations. Sharing patient information, especially sensitive details like an obituary, on social media platforms is a serious violation of privacy and can lead to legal consequences.
Choice D rationale:
The nurse discards copies of patient information into the regular trash bin. This action is inappropriate and violates patient confidentiality. Proper disposal of patient information is crucial to protect patient privacy and comply with regulations. Patient documents should be shredded or disposed of in designated secure bins to prevent unauthorized access to sensitive information.
Choice E rationale:
The nurse accesses the nurse's own health record via computer. This action is inappropriate unless there is a legitimate reason related to patient care. Accessing one's own health record without a valid purpose is a breach of patient privacy and can lead to disciplinary actions. Healthcare professionals should only access patient records when necessary for providing care and treatment.
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