5.4.2: FRAME 2- Analyze Cues
- Page ID
- 90260
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CORRECT Answer
Question Type: Matrix Multiple Response
Scoring: 0/1
NCSBN Item Type and Scoring: https://www.ncsbn.org/public-files/p...main_stage.pdf
After reviewing the client information, determine the cues that are relevant or irrelevant to the client’s current status. Each row should include a single choice.
| Finding | Relevant | Irrelevant |
|---|---|---|
| Client flat affect and low-spirits | X | |
| Diminished breath sounds | X | |
| Bowel sounds hypoactive | X | |
| Weakness | X | |
| Reddened wound borders | X | |
| Heart rate | X | |
| Temperature | X | |
| Sp02 | X | |
| WBC value | X | |
| Hemoglobin value | X | |
| Red blood cell value | X | |
| Occasional alcohol use | X | |
| Occupation | X | |
| History of depression | X |
RATIONALE
Jacklyn is facing physiological issues with her low hemoglobin and red blood cell values, therefore causing her abnormal Sp02, weakness, and diminished breath sounds. Additionally, Jacklyn is predisposed to depression, and it is important for the nurse to recognize the significance of this in Jacklyn’s history. Post-operative depression in major surgery is noted to delay post-operative recovery and given Jacklyn’s current situation puts her at high risk. Therefore, Jacklyn’s flat affect, low-spirits, and history of depression are certainly relevant to her current status. Lastly, it is important for the nurse to recognize the relevancy of Jacklyn’s occupation and relate it to the type of surgery she just had. Because of the midsternal incision, Jacklyn will want to take sternal precautions for quite some time, and if she is required to push/pull/carry more than 10 lbs., she will not be able to perform her job the way she could before surgery.
FOCUSED GUIDE
Therapeutic communication is the exchange of both non-verbal and verbal methods. Therapeutic communication style may help clients overcome some of the emotional or psychological distress they experience (Sharma & Gupta, 2023). Empathetic communication occurs when an individual acknowledges another’s emotions and responds in a way that shows caring and concern. Empathy in communication is simply understanding and sharing the feelings of another person. Recognizing the importance of quality communication with Jacklyn is essential based on her mental health history and the barriers she is facing post-operatively.
The second SDOH domain addressed in this case study is Social and Community Context. Recognizing SDOH are the social conditions in which people are born, live and work, play, worship, and go to school establish a fundamental understanding into rationalizing health concerns and outcomes of clients. Additionally, SDOH offers a more inclusive view on how one’s geographic location, neighborhood, and access to health care play a critical role in morbidity and mortality. It is expected SDOH will continue to increase in relevance and integration of client management both in acute and community health settings especially as health care organizations look to achieve equity and decrease health disparities among different populations (Brandt et al., 2023).
The goal of the domain, Social and Community Context is to increase social and community support. Jacklyn’s commitment to her religious beliefs and relationship with her church can positively impact on her recovery and ongoing health and well-being. Jacklyn is experiencing depressive symptoms and may find solace in fellowship with members from the Kingdom Hall and in prayer. This interaction would meet the Social and Community Context objective, increase the proportion of adults who talk with friends and family about their health (HC/HIT-04).