NR 509 SOAP Note Week 6 Course Advanced
Physical Assessment (NR-509) - Chamberlain
College Of Nursing (NR 509 Advanced Physical
Assessment)
Section 1: SOAP Note Structure & Documentation Standards
Question 1
Which component of the SOAP note includes the patient's chief complaint and subjective
symptoms?
A. Subjective
B. Objective
C. Assessment
D. Plan
Rationale: The Subjective section captures the patient's own report of symptoms, concerns,
and experiences. It includes the chief complaint, history of present illness using OLDCARTS,
review of systems, past medical history, medications, and allergies. Objective data is what you
observe and measure, Assessment is your clinical reasoning, and Plan is the management
strategy .
Question 2
What is the primary purpose of the Objective section in a SOAP note?
A. Document patient concerns
B. Record measurable and observable data
C. Diagnose conditions
D. Outline treatment plan
Rationale: The Objective section includes vital signs, physical exam findings, laboratory
results, and imaging studies—all data that is measurable and observable by the clinician. Patient
concerns belong in Subjective, diagnoses in Assessment, and treatment in Plan .
,Question 3
During a pediatric SOAP note, which finding should be documented as Objective data?
A. Parent reports vomiting
B. Child complains of ear pain
C. Otoscopic exam shows bulging tympanic membrane
D. History of present illness
Rationale: Otoscopic examination findings are directly observed and measurable by the
clinician, making them Objective data. Parent-reported vomiting and child-reported ear pain are
Subjective findings from the history. The HPI is part of the Subjective section .
Question 4
Which is the most appropriate entry for the Assessment section of a SOAP note?
A. Parent reports wheezing
B. Crackles noted bilaterally
C. Acute viral bronchiolitis
D. Albuterol prescribed
Rationale: The Assessment section contains the clinical impression, diagnosis, or differential
diagnosis. "Acute viral bronchiolitis" is a diagnosis. Wheezing reported by a parent is Subjective,
crackles noted on exam are Objective, and prescribed medications belong in the Plan .
Question 5
Which is an appropriate entry for the Plan section of a SOAP note?
A. Child appears ill
B. Cough present
C. Administer acetaminophen 15 mg/kg PRN for fever
D. Weight 12 kg
Rationale: The Plan includes treatment strategies, medications, patient education, referrals,
and follow-up. "Administer acetaminophen 15 mg/kg PRN" is a treatment order. "Child appears
ill" is an Objective observation, "cough present" is a symptom that could be Subjective or
Objective, and weight is Objective data .
,Question 6
In a pediatric SOAP note, anticipatory guidance belongs in which section?
A. Subjective
B. Objective
C. Assessment
D. Plan
Rationale: Anticipatory guidance—including injury prevention, nutrition counseling, and
developmental expectations—is part of health promotion and education, which belongs in the
Plan section. It outlines what will be done to promote the patient's health and prevent future
issues .
Question 7
When documenting growth charts in a pediatric SOAP note, which percentile range is
generally considered normal?
A. 3rd–97th percentile
B. 50th–100th percentile
C. 25th–75th percentile
D. 10th–90th percentile
Rationale: Growth percentiles between the 3rd and 97th are generally considered within
normal limits. Values below the 3rd percentile may indicate failure to thrive or growth
restriction, while values above the 97th may suggest macrosomia or endocrine concerns .
Question 8
Which statement about pediatric medication dosing documentation is correct?
A. Dosing is based on age
B. Dosing is based on height
C. Dosing is based on weight
D. Dosing is based on gender
Rationale: Pediatric medication dosing is weight-based (mg/kg) to ensure safety and
efficacy. Age, height, and gender are not the primary determinants for most pediatric
medications. Weight should be documented in kilograms for accurate calculation .
, Question 9
Which finding supports dehydration in a toddler?
A. Moist mucous membranes
B. Sunken fontanelle
C. Increased urine output
D. Weight gain
Rationale: A sunken fontanelle indicates dehydration in an infant or toddler whose anterior
fontanelle has not yet closed. Moist mucous membranes, increased urine output, and weight
gain are all signs of adequate hydration, not dehydration .
Question 10
Which symptom is considered a red flag in a pediatric SOAP note?
A. Mild rhinorrhea
B. Playful behavior
C. Poor feeding in an infant
D. Clear lung sounds
Rationale: Poor feeding in an infant is a serious red flag that may indicate sepsis, serious
infection, metabolic disorder, or other critical illness. Mild rhinorrhea, playful behavior, and
clear lung sounds are reassuring findings .
Question 11
Which vital sign is most critical to interpret using age-specific norms in pediatrics?
A. Blood pressure
B. Heart rate
C. Oxygen saturation
D. Temperature
Rationale: Heart rate varies significantly with age in pediatrics—newborns normally have
heart rates of 100–160 bpm, while adolescents have rates of 60–100 bpm. Using adult norms
for pediatric patients could lead to misinterpretation of tachycardia or bradycardia .
Physical Assessment (NR-509) - Chamberlain
College Of Nursing (NR 509 Advanced Physical
Assessment)
Section 1: SOAP Note Structure & Documentation Standards
Question 1
Which component of the SOAP note includes the patient's chief complaint and subjective
symptoms?
A. Subjective
B. Objective
C. Assessment
D. Plan
Rationale: The Subjective section captures the patient's own report of symptoms, concerns,
and experiences. It includes the chief complaint, history of present illness using OLDCARTS,
review of systems, past medical history, medications, and allergies. Objective data is what you
observe and measure, Assessment is your clinical reasoning, and Plan is the management
strategy .
Question 2
What is the primary purpose of the Objective section in a SOAP note?
A. Document patient concerns
B. Record measurable and observable data
C. Diagnose conditions
D. Outline treatment plan
Rationale: The Objective section includes vital signs, physical exam findings, laboratory
results, and imaging studies—all data that is measurable and observable by the clinician. Patient
concerns belong in Subjective, diagnoses in Assessment, and treatment in Plan .
,Question 3
During a pediatric SOAP note, which finding should be documented as Objective data?
A. Parent reports vomiting
B. Child complains of ear pain
C. Otoscopic exam shows bulging tympanic membrane
D. History of present illness
Rationale: Otoscopic examination findings are directly observed and measurable by the
clinician, making them Objective data. Parent-reported vomiting and child-reported ear pain are
Subjective findings from the history. The HPI is part of the Subjective section .
Question 4
Which is the most appropriate entry for the Assessment section of a SOAP note?
A. Parent reports wheezing
B. Crackles noted bilaterally
C. Acute viral bronchiolitis
D. Albuterol prescribed
Rationale: The Assessment section contains the clinical impression, diagnosis, or differential
diagnosis. "Acute viral bronchiolitis" is a diagnosis. Wheezing reported by a parent is Subjective,
crackles noted on exam are Objective, and prescribed medications belong in the Plan .
Question 5
Which is an appropriate entry for the Plan section of a SOAP note?
A. Child appears ill
B. Cough present
C. Administer acetaminophen 15 mg/kg PRN for fever
D. Weight 12 kg
Rationale: The Plan includes treatment strategies, medications, patient education, referrals,
and follow-up. "Administer acetaminophen 15 mg/kg PRN" is a treatment order. "Child appears
ill" is an Objective observation, "cough present" is a symptom that could be Subjective or
Objective, and weight is Objective data .
,Question 6
In a pediatric SOAP note, anticipatory guidance belongs in which section?
A. Subjective
B. Objective
C. Assessment
D. Plan
Rationale: Anticipatory guidance—including injury prevention, nutrition counseling, and
developmental expectations—is part of health promotion and education, which belongs in the
Plan section. It outlines what will be done to promote the patient's health and prevent future
issues .
Question 7
When documenting growth charts in a pediatric SOAP note, which percentile range is
generally considered normal?
A. 3rd–97th percentile
B. 50th–100th percentile
C. 25th–75th percentile
D. 10th–90th percentile
Rationale: Growth percentiles between the 3rd and 97th are generally considered within
normal limits. Values below the 3rd percentile may indicate failure to thrive or growth
restriction, while values above the 97th may suggest macrosomia or endocrine concerns .
Question 8
Which statement about pediatric medication dosing documentation is correct?
A. Dosing is based on age
B. Dosing is based on height
C. Dosing is based on weight
D. Dosing is based on gender
Rationale: Pediatric medication dosing is weight-based (mg/kg) to ensure safety and
efficacy. Age, height, and gender are not the primary determinants for most pediatric
medications. Weight should be documented in kilograms for accurate calculation .
, Question 9
Which finding supports dehydration in a toddler?
A. Moist mucous membranes
B. Sunken fontanelle
C. Increased urine output
D. Weight gain
Rationale: A sunken fontanelle indicates dehydration in an infant or toddler whose anterior
fontanelle has not yet closed. Moist mucous membranes, increased urine output, and weight
gain are all signs of adequate hydration, not dehydration .
Question 10
Which symptom is considered a red flag in a pediatric SOAP note?
A. Mild rhinorrhea
B. Playful behavior
C. Poor feeding in an infant
D. Clear lung sounds
Rationale: Poor feeding in an infant is a serious red flag that may indicate sepsis, serious
infection, metabolic disorder, or other critical illness. Mild rhinorrhea, playful behavior, and
clear lung sounds are reassuring findings .
Question 11
Which vital sign is most critical to interpret using age-specific norms in pediatrics?
A. Blood pressure
B. Heart rate
C. Oxygen saturation
D. Temperature
Rationale: Heart rate varies significantly with age in pediatrics—newborns normally have
heart rates of 100–160 bpm, while adolescents have rates of 60–100 bpm. Using adult norms
for pediatric patients could lead to misinterpretation of tachycardia or bradycardia .
