NU 518 Comprehensive SOAP Note CJ 27-Year-Old Actual
Exam 2026/2027 – Complete Clinical Reasoning &
Documentation with Detailed Rationales | 100% Verified |
Pass Guaranteed – A+ Graded
SECTION A: SUBJECTIVE DATA – COMPREHENSIVE HISTORY FOR CJ
(Q1–Q6)
Q1: Which type of information belongs in the "S" (Subjective) section of the SOAP note?
A. Vital signs and physical examination findings
B. Laboratory results and imaging reports
C. Information reported by the patient, such as symptoms, feelings, and health history
[CORRECT]
D. Diagnoses and differential diagnoses
Correct Answer: C
Rationale: Subjective data are what the patient reports — symptoms, history, and
perceptions; measurable examiner findings belong in Objective, and diagnoses and
orders belong in Assessment and Plan.
Q2: CJ, a 27-year-old, states, "My throat has been so sore for the past four days that I
can barely swallow." How should the NP document this statement in the SOAP note?
A. As the chief complaint in the patient's own words [CORRECT]
B. As the assessment diagnosis
C. As objective physical examination data
D. As the treatment plan
Correct Answer: A
Rationale: The chief complaint is a brief statement of why the patient seeks care, ideally
quoted in the patient's own words; it is not a diagnosis, an exam finding, or part of the
plan.
Q3: During the HPI, the NP asks CJ, "When exactly did the sore throat begin?" Which
element of OLDCARTS does this question address?
A. Characteristics
B. Onset [CORRECT]
C. Aggravating factors
, D. Radiation
Correct Answer: B
Rationale: Asking when the symptom began assesses Onset in the OLDCARTS
mnemonic; characteristics, aggravating factors, and radiation each address different
elements of symptom analysis.
Q4: CJ reports, "When I took amoxicillin at age 10, I broke out in hives and my lips
swelled." Where should this information be documented, and why does it matter?
A. Family history — it only matters for her relatives
B. Review of systems — it describes a rash
C. Social history — lifestyle section
D. In the allergy history within the subjective data — because it will change antibiotic
selection in the Plan [CORRECT]
Correct Answer: D
Rationale: Hives with lip swelling suggests an IgE-mediated penicillin allergy that must
be recorded in the allergy history because it will drive selection of a non-beta-lactam
antibiotic; it is neither family history, a routine ROS item, nor lifestyle data.
Q5: CJ reports smoking half a pack per day, three sexual partners in the past year, and
inconsistent condom use. What is the NP's BEST action during subjective data
collection?
A. Document that CJ is "noncompliant with healthy living"
B. Skip these topics because they are unrelated to a sore throat
C. Complete a thorough social history — including alcohol, substance use, sexual
history, and contraception — because these findings guide screening and counseling
[CORRECT]
D. Lecture CJ that her lifestyle is dangerous before finishing the history
Correct Answer: C
Rationale: Social risk factors guide preventive screening (STI testing, smoking cessation
counseling) and belong in a complete history; judgmental labels and skipping data
undermine comprehensive, unbiased assessment.
Q6: During the review of systems, CJ states, "It's getting hard to open my mouth all the
way, and I keep drooling a little." What should the NP do?
A. Recognize possible airway compromise from a peritonsillar abscess and assess CJ
immediately as the priority [CORRECT]
B. Document it as an expected finding and continue the routine interview
C. Schedule routine follow-up in two weeks
D. Advise CJ to drink extra water and rest
Correct Answer: A
Exam 2026/2027 – Complete Clinical Reasoning &
Documentation with Detailed Rationales | 100% Verified |
Pass Guaranteed – A+ Graded
SECTION A: SUBJECTIVE DATA – COMPREHENSIVE HISTORY FOR CJ
(Q1–Q6)
Q1: Which type of information belongs in the "S" (Subjective) section of the SOAP note?
A. Vital signs and physical examination findings
B. Laboratory results and imaging reports
C. Information reported by the patient, such as symptoms, feelings, and health history
[CORRECT]
D. Diagnoses and differential diagnoses
Correct Answer: C
Rationale: Subjective data are what the patient reports — symptoms, history, and
perceptions; measurable examiner findings belong in Objective, and diagnoses and
orders belong in Assessment and Plan.
Q2: CJ, a 27-year-old, states, "My throat has been so sore for the past four days that I
can barely swallow." How should the NP document this statement in the SOAP note?
A. As the chief complaint in the patient's own words [CORRECT]
B. As the assessment diagnosis
C. As objective physical examination data
D. As the treatment plan
Correct Answer: A
Rationale: The chief complaint is a brief statement of why the patient seeks care, ideally
quoted in the patient's own words; it is not a diagnosis, an exam finding, or part of the
plan.
Q3: During the HPI, the NP asks CJ, "When exactly did the sore throat begin?" Which
element of OLDCARTS does this question address?
A. Characteristics
B. Onset [CORRECT]
C. Aggravating factors
, D. Radiation
Correct Answer: B
Rationale: Asking when the symptom began assesses Onset in the OLDCARTS
mnemonic; characteristics, aggravating factors, and radiation each address different
elements of symptom analysis.
Q4: CJ reports, "When I took amoxicillin at age 10, I broke out in hives and my lips
swelled." Where should this information be documented, and why does it matter?
A. Family history — it only matters for her relatives
B. Review of systems — it describes a rash
C. Social history — lifestyle section
D. In the allergy history within the subjective data — because it will change antibiotic
selection in the Plan [CORRECT]
Correct Answer: D
Rationale: Hives with lip swelling suggests an IgE-mediated penicillin allergy that must
be recorded in the allergy history because it will drive selection of a non-beta-lactam
antibiotic; it is neither family history, a routine ROS item, nor lifestyle data.
Q5: CJ reports smoking half a pack per day, three sexual partners in the past year, and
inconsistent condom use. What is the NP's BEST action during subjective data
collection?
A. Document that CJ is "noncompliant with healthy living"
B. Skip these topics because they are unrelated to a sore throat
C. Complete a thorough social history — including alcohol, substance use, sexual
history, and contraception — because these findings guide screening and counseling
[CORRECT]
D. Lecture CJ that her lifestyle is dangerous before finishing the history
Correct Answer: C
Rationale: Social risk factors guide preventive screening (STI testing, smoking cessation
counseling) and belong in a complete history; judgmental labels and skipping data
undermine comprehensive, unbiased assessment.
Q6: During the review of systems, CJ states, "It's getting hard to open my mouth all the
way, and I keep drooling a little." What should the NP do?
A. Recognize possible airway compromise from a peritonsillar abscess and assess CJ
immediately as the priority [CORRECT]
B. Document it as an expected finding and continue the routine interview
C. Schedule routine follow-up in two weeks
D. Advise CJ to drink extra water and rest
Correct Answer: A
