What is a SOAP note? a. Record of supplies used in patient ...

[SAVANNAHHOOPER23]

What is a SOAP note?
 
  a. Record of supplies used in patient hygiene
  b. Record of an event during a patient's stay, formatted according to the Simple Object Access Protocol (SOAP), enabling it to be easily transmitted between computers
  c. Form of bar code
  d. Record of patient data listing the patient's subjective complaint, objective data rec-orded by the nurse, the nurse's assessment of the situation, and the nurse's plan of action

Question 2

A home health nurse is completing an admission on a patient who recently experienced a transient ischemic attack (TIA). During the assessment, the patient begins to complain of a severe headache and numbness in his left arm.
 
  Which action should the nurse take next? a. Instruct the patient to take Tylenol.
  b. Ask whether patient suffers from migraine headaches.
  c. Reschedule the visit.
  d. Call 9-1-1

[taylorsonier]

Answer to Question 1

D
SOAP stands for subjective (patient complaint), objective (observed data), assessment, and plan. A SOAP note is a record of an event in which a patient makes a subjective complaint and the nurse observes objective data, makes an assessment on the basis of the complaint and the data, and makes a plan for interventions based on the assessment. A SOAP note is a record in human language describing a problem, its assessment, and planned interventions.

Answer to Question 2

D
The home health nurse should immediately call 9-1-1 . Approximately 24 to 29 of those who have a TIA will have a stroke within 5 years after the event (Goldstein, 2011). Tylenol would not be advised. The nurse should not leave the patient until the patient is en route to the emergency department.