The nurse is reviewing flow chart entries for a client ...

[V@ndy87]

The nurse is reviewing flow chart entries for a client experiencing pain. Which chart entries represent subjective data?
 
  1. The client's leg is red and swollen.
  2. The client complains of leg tenderness.
  3. The client's white blood cell count is 5.6.
  4. The client demonstrates guarding behaviors during the assessment of the affected extremity.
  5. The client complains leg cramps.

Question 2

The nurse manager is reviewing SOAP entries in the medical record for a novice nurse. Which entry indicates that the nurse needs further instruction concerning documentation?
 
  1. S: The client states, I am so nauseated.
  2. O: The client reports feeling fatigued.
  3. A: Bowel sounds are high-pitched in all abdominal quadrants.
  4. P: The client will remain NPO.

[nhea]

Answer to Question 1

Correct Answer: 2, 5

Subjective information refers to data reported by the client. The client's complaints are an example of subjective information. Objective information is observable by the examiner. The examiner is able to visualize the appearance of the extremity. The laboratory values are objective data that can be determined by a technician. The presence of guarding behaviors may be noted by the examiner.

Answer to Question 2

Correct Answer: 2

SOAP charting is a problem-oriented system of documentation. S refers to subjective data; client reports are examples of subjective information. O refers to objective data; objective information is observable by the examiner. Report of fatigue is an example of subjective information. A refers to assessment; the characteristics of the client's bowel sounds represent an assessment. P refers to planning; planning indicates actions taken to resolve or address the client's needs. The client will remain NPO represents an action taken or plan to address the client's needs.

[V@ndy87]

Wow, this really help

[xiaomengxian]

Thanks for the timely response, appreciate it