When using the SOAP method of charting, S stands for subjective data which means:

patient provided data

all of the answers are correct

observed data

measured data

Answer and Explanation

The Correct Answer is A

A. Patient provided data: Subjective data includes information the patient states, such as symptoms, pain level, or concerns.

B. All of the answers are correct: Not all answer choices describe subjective data.

C. Observed data: Observations made by the nurse (e.g., swelling, pallor) are objective, not subjective.

D. Measured data: Measurable data, such as vital signs, are objective, not subjective.

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Correct Answer is C

Explanation

A. The care plan: While important for care, the care plan alone does not provide a full picture of patient care over time.

B. The medical orders: Medical orders show physician instructions but do not capture the full scope of patient care.

C. The entire record: The entire medical record can be subpoenaed and used as legal evidence, including notes, orders, test results, and nursing documentation.

D. Nursing notes: Nursing notes are part of the medical record but do not represent the full legal documentation on their own.

A. use a Nursing Diagnosis from a source other than NANDA-I B. limit the number of interventions C. select interventions which will be easy to implement D. involve the patient in the process

Correct Answer is D

Explanation

A. Use a Nursing Diagnosis from a source other than NANDA-I: NANDA-I provides standardized nursing diagnoses that ensure accurate problem identification and care planning.

B. Limit the number of interventions: Interventions should be appropriate and sufficient rather than arbitrarily limited.

C. Select interventions which will be easy to implement: Interventions should be effective and individualized, not just easy.

D. Involve the patient in the process: Patient involvement ensures better adherence, understanding, and personalized care.

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When using the SOAP method of charting, S stands for subjective data which means:

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Naxlex Comprehensive Predictor Exams

Which part of the medical record can be used as evidence in court?

Correct Answer is C

Explanation

A patient with edema has a problem of fluid overload. The nurse is developing a care plan and selecting interventions that will assist the patient in reducing the fluid. An important consideration when developing the care plan is to:

Correct Answer is D

Explanation

Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

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When using the SOAP method of charting, S stands for subjective data which means:

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