Documentation System
Documentation System ( 5 Questions)
A nurse is using the SOAP format to write a progress note for a client who has impaired physical mobility.
Which of the following statements should the nurse include as the subjective data?
It is objective data, which is measurable and observable by the nurse or other healthcare providers. Objective data is what the nurse sees, hears, feels, or smells.
This is the subjective data because it is based on the client’s own perception and feelings. Subjective data is what the client tells the nurse or what the nurse observes from the client’s behavior.
It is also objective data, as it can be measured by the nurse using a goniometer or other tools.
It is also objective data, as it can be observed by the nurse or documented in the care plan.
“The client reports feeling less pain in his left leg.”
This is the subjective data because it is based on the client’s own perception and feelings. Subjective data is what the client tells the nurse or what the nurse observes from the client’s behavior.
Choice A is wrong because it is objective data, which is measurable and observable by the nurse or other healthcare providers. Objective data is what the nurse sees, hears, feels, or smells.
Choice C is wrong because it is also objective data, as it can be measured by the nurse using a goniometer or other tools.
Choice D is wrong because it is also objective data, as it can be observed by the nurse or documented in the care plan.
Normal ranges for vital signs are as follows:.
• Blood pressure: 90/60 mmHg to 120/80 mmHg.
• Pulse rate: 60 to 100 beats per minute.
• Respiratory rate: 12 to 20 breaths per minute.
• SpO2: 95% to 100%.
• Temperature: 36.5°C to 37.5°C.