NR 509 SOAP Note Week 6 Course Advanced
Physical Assessment (NR-509) - Chamberlain
College Of Nursing (NR 509 Advanced Physical
Assessment
Section I: SOAP Note Structure & Documentation Principles
1. A nurse practitioner documents the following in a pediatric SOAP note:
“Mother reports the child has been coughing for 5 days and has had a fever of
101.2°F at home.” Which section of the SOAP note does this belong in?
A. Subjective
B. Objective
C. Assessment
D. Plan
Correct Answer: A
Rationale: Information reported by the patient or caregiver—including
symptoms, duration, and home measurements—is subjective data. The SOAP
note’s Subjective section captures the patient’s or caregiver’s account of the
illness, including chief complaint, history of present illness, past medical history,
and review of systems .
2. Which of the following is documented in the Objective section of a pediatric
SOAP note?
A. “Child reports right ear pain 3/10”
B. “Otoscopic examination reveals a bulging, erythematous right tympanic
membrane”
,C. “Acute otitis media”
D. “Amoxicillin 80 mg/kg/day divided BID”
Correct Answer: B
Rationale: The Objective section contains measurable, observable, and
verifiable data obtained by the clinician, including physical examination findings,
vital signs, and laboratory results . A bulging, erythematous tympanic membrane
is a direct observation. Option A is subjective (patient report), C is assessment,
and D is plan.
3. In a pediatric SOAP note, the “A” section should include which of the following?
A. The child’s chief complaint in their own words
B. Vital signs and physical exam findings
C. Clinical impression, diagnosis, or differential diagnoses
D. Medication dosing and follow-up instructions
Correct Answer: C
Rationale: The Assessment section synthesizes subjective and objective
data into a clinical impression, diagnosis, or differential diagnosis list . It
represents the clinician’s clinical reasoning and interpretation of findings.
4. A nurse practitioner is documenting a well-child visit for a 4-year-old. Which
finding belongs in the Subjective section?
A. “Temperature 37.2°C”
B. “Heart rate 100 bpm”
C. “Mother states child has been eating well and sleeping through the night”
D. “Lungs clear to auscultation bilaterally”
Correct Answer: C
Rationale: Parental report of the child’s eating and sleeping habits is
subjective data provided by the caregiver. Vital signs and auscultation findings are
objective data measured or observed by the clinician .
,5. Which statement best describes the purpose of the Plan section in a pediatric
SOAP note?
A. To summarize the patient’s history
B. To document the physical examination findings
C. To outline diagnostic testing, treatment, education, and follow-up
D. To list the patient’s medications
Correct Answer: C
Rationale: The Plan section details the management strategy, including
diagnostic tests ordered, pharmacologic and non-pharmacologic interventions,
patient/caregiver education, referrals, and follow-up scheduling .
6. A nurse practitioner documents: “8-year-old male with 5-day history of
productive cough and subjective fever, now presenting with increased work of
breathing.” This statement is best classified as:
A. Chief complaint
B. History of present illness
C. Review of systems
D. Past medical history
Correct Answer: B
Rationale: The History of Present Illness (HPI) is a chronological narrative
of the current illness, including onset, duration, characteristics,
aggravating/relieving factors, and associated symptoms. This statement provides
a focused narrative of the current problem .
7. Which of the following is an example of Objective data in a pediatric SOAP
note?
A. “Child complains of sore throat”
B. “Mother reports decreased oral intake”
, C. “Pharynx erythematous with white exudate on tonsils”
D. “Child appears fussy per mother”
Correct Answer: C
Rationale: Direct visualization of pharyngeal erythema and tonsillar
exudate is an objective clinical finding. Options A and B are reported symptoms
(subjective), and D is a caregiver observation, which is also subjective unless the
clinician independently makes a behavioral observation .
8. In a pediatric SOAP note, where should immunization status be documented?
A. Subjective section, under Past Medical History
B. Objective section, under Physical Exam
C. Assessment section, as a diagnosis
D. Plan section, as an intervention
Correct Answer: A
Rationale: Immunization history is part of the patient’s Past Medical
History (PMHx), which is documented in the Subjective section. It is reported
information obtained from the caregiver or patient .
9. A nurse practitioner documents: “Child’s father smokes cigars in the home;
child reports occasional exposure to secondhand smoke.” This information
belongs in which section?
A. Chief complaint
B. Social history
C. Review of systems
D. Physical examination
Correct Answer: B
Rationale: Social history includes information about the patient’s living
environment, family structure, tobacco exposure, and other social determinants
of health. This is documented within the Subjective section .
Physical Assessment (NR-509) - Chamberlain
College Of Nursing (NR 509 Advanced Physical
Assessment
Section I: SOAP Note Structure & Documentation Principles
1. A nurse practitioner documents the following in a pediatric SOAP note:
“Mother reports the child has been coughing for 5 days and has had a fever of
101.2°F at home.” Which section of the SOAP note does this belong in?
A. Subjective
B. Objective
C. Assessment
D. Plan
Correct Answer: A
Rationale: Information reported by the patient or caregiver—including
symptoms, duration, and home measurements—is subjective data. The SOAP
note’s Subjective section captures the patient’s or caregiver’s account of the
illness, including chief complaint, history of present illness, past medical history,
and review of systems .
2. Which of the following is documented in the Objective section of a pediatric
SOAP note?
A. “Child reports right ear pain 3/10”
B. “Otoscopic examination reveals a bulging, erythematous right tympanic
membrane”
,C. “Acute otitis media”
D. “Amoxicillin 80 mg/kg/day divided BID”
Correct Answer: B
Rationale: The Objective section contains measurable, observable, and
verifiable data obtained by the clinician, including physical examination findings,
vital signs, and laboratory results . A bulging, erythematous tympanic membrane
is a direct observation. Option A is subjective (patient report), C is assessment,
and D is plan.
3. In a pediatric SOAP note, the “A” section should include which of the following?
A. The child’s chief complaint in their own words
B. Vital signs and physical exam findings
C. Clinical impression, diagnosis, or differential diagnoses
D. Medication dosing and follow-up instructions
Correct Answer: C
Rationale: The Assessment section synthesizes subjective and objective
data into a clinical impression, diagnosis, or differential diagnosis list . It
represents the clinician’s clinical reasoning and interpretation of findings.
4. A nurse practitioner is documenting a well-child visit for a 4-year-old. Which
finding belongs in the Subjective section?
A. “Temperature 37.2°C”
B. “Heart rate 100 bpm”
C. “Mother states child has been eating well and sleeping through the night”
D. “Lungs clear to auscultation bilaterally”
Correct Answer: C
Rationale: Parental report of the child’s eating and sleeping habits is
subjective data provided by the caregiver. Vital signs and auscultation findings are
objective data measured or observed by the clinician .
,5. Which statement best describes the purpose of the Plan section in a pediatric
SOAP note?
A. To summarize the patient’s history
B. To document the physical examination findings
C. To outline diagnostic testing, treatment, education, and follow-up
D. To list the patient’s medications
Correct Answer: C
Rationale: The Plan section details the management strategy, including
diagnostic tests ordered, pharmacologic and non-pharmacologic interventions,
patient/caregiver education, referrals, and follow-up scheduling .
6. A nurse practitioner documents: “8-year-old male with 5-day history of
productive cough and subjective fever, now presenting with increased work of
breathing.” This statement is best classified as:
A. Chief complaint
B. History of present illness
C. Review of systems
D. Past medical history
Correct Answer: B
Rationale: The History of Present Illness (HPI) is a chronological narrative
of the current illness, including onset, duration, characteristics,
aggravating/relieving factors, and associated symptoms. This statement provides
a focused narrative of the current problem .
7. Which of the following is an example of Objective data in a pediatric SOAP
note?
A. “Child complains of sore throat”
B. “Mother reports decreased oral intake”
, C. “Pharynx erythematous with white exudate on tonsils”
D. “Child appears fussy per mother”
Correct Answer: C
Rationale: Direct visualization of pharyngeal erythema and tonsillar
exudate is an objective clinical finding. Options A and B are reported symptoms
(subjective), and D is a caregiver observation, which is also subjective unless the
clinician independently makes a behavioral observation .
8. In a pediatric SOAP note, where should immunization status be documented?
A. Subjective section, under Past Medical History
B. Objective section, under Physical Exam
C. Assessment section, as a diagnosis
D. Plan section, as an intervention
Correct Answer: A
Rationale: Immunization history is part of the patient’s Past Medical
History (PMHx), which is documented in the Subjective section. It is reported
information obtained from the caregiver or patient .
9. A nurse practitioner documents: “Child’s father smokes cigars in the home;
child reports occasional exposure to secondhand smoke.” This information
belongs in which section?
A. Chief complaint
B. Social history
C. Review of systems
D. Physical examination
Correct Answer: B
Rationale: Social history includes information about the patient’s living
environment, family structure, tobacco exposure, and other social determinants
of health. This is documented within the Subjective section .
