Ch 13 Care/ Case Management

2. A community/public health nurse is visiting a family for the first time. Which of the following should be the priority action for the nurse? a. Assessing how the family is adjusting to the illness of the sick family member b. Clarifying what insurance or third-party payer is reimbursing this care c. Determining the problem or reason for the referral d. Establishing a relationship with the family

ANS: D Although all of the options are important aspects of planning care, the nurse's ability to establish a relationship in which the family's rights and strengths are respected is more important than any other task.

14. A community/public health nurse is teaching a family about how to care for an ill member of the family. Upon which family member should the nurse focus on teaching? a. Teach the family member with the most resilience and competence to do what must be done to ensure that it gets done. b. Teach the ill member what must be done because he or she is responsible for his or her own care. c. Teach the weakest family member what must be done because that will strengthen his or her position in the family. d. Teach the wife or mother what must be done because caring for others is a female role and expectation.

ANS: A For maximum effectiveness, the nurse should teach the strongest member, who is most able to change. That member may be able to delegate some responsibilities to others in the family.

2. A community/public health nurse is drawing a genogram about a client's extended family. Which of the following purposes would this serve? (Select all that apply.) a. Beginning with such a neutral task can help establish rapport. b. Connections between events and relationships may be more clearly perceived. c. A genogram establishes medical history and possible genetic vulnerabilities. d. A genogram helps decrease negative feelings about a relationship. e. A genogram helps share the family's perception of their own structure. f. A genogram allows the family to reveal information about family secrets.

ANS: A, B, C, D, E A genogram is a map of family relationships for at least three generations that helps the family and nurse recognize important patterns and significant events in an objective way. The process is a way to safely begin to establish rapport. The genogram demonstrates relationships but also, in a calm and factual way, determines how the family members feel about other family members during the process.

8. Which of the following actions should a nurse take to minimize the effort required in evaluating the success of interventions with a family? (Select all that apply.) a. Choose criteria for evaluation that will demonstrate the value of the nursing interventions. b. Evaluate care on the basis of the goals that the family and nurse together agreed upon. c. Gather all possible data throughout the intervention so the data will be available for evaluation purposes. d. Plan for evaluation while beginning assessment of the family. e. Inform the family that they must contribute data for evaluation when it is requested. f. Use only short-term criteria so the data can be gathered before care is terminated.

ANS: A, B, D Even though evaluation is the final step of the nursing process, it is also a step that starts at the beginning of the contact and occurs continually as the contact progresses. The word evaluate means to determine worth. Many methods can be used to evaluate nursing care, but the key to evaluation is to determine the correct criteria that demonstrate the value of the nursing contact. Criteria for evaluating client outcomes are derived from the objectives developed with the family. Only data relevant to the nurse's intervention are collected. Because the outcomes of nursing interventions occurring during one visit may not be apparent until later, both long-term and short-term evaluative criteria should be developed. The family does not have to contribute data unless they choose to do so.

4. Why is it necessary for a nurse to assess strengths when the primary reason for being in the home is to assist with areas of need? (Select all that apply.) a. Such assessment helps the family recognize their own assets. b. It creates a forum for change as family perspective changes. c. It allows the family to avoid becoming depressed about the situation. d. It helps the family see problem behaviors as assets to be used. e. It allows the nurse to identify resources that can be used to address areas of need. f. It promotes use of strengths in a different context.

ANS: A, B, D, E, F Nurses use the strengths of the family to address the areas of need, but strengths must first be recognized or perceived by the family as assets. Even asking questions about strengths can be therapeutic and can help families recognize their own abilities. Problem behaviors may be reframed as areas of strength that might be very useful in a different context.

9. Before terminating care with a family, which of the following actions should a nurse accomplish? (Select all that apply.) a. Allow the family members to express their feelings and reactions to having to terminate care. b. Develop established criteria so the family knows when to seek care in the future. c. Encourage crying or other actions to demonstrate their grief and loss. d. Express the nurse's feelings about having to end the relationship. e. Remind the family of the date or goal accomplishment that represents the time for termination. f. Say goodbye for now, but plan to keep in touch with the family.

ANS: A, B, E Careful planning, advance notice, and talking about the emotions and issues that arise are helpful for everyone involved. The nurse may often address the issue of termination before the client is ready to discuss it. Allowing clients to express reactions and helping families perceive themselves as being able to master upcoming situations independently will help the family make the transition to independence and termination. During the final visits, the nurse begins to prepare the family by reminding them that the time together is limited. A date or goal should be set that is understood as the marking point for termination. Criteria should be established for the family to know when to seek health care again.

7. What would be the most appropriate action for a nurse to take when helping a family who is in crisis when the husband/father of the family died suddenly? (Select all that apply.) a. Assisting the family in reaching out to friends and neighbors for help b. Being an emotional support for the family c. Helping the family identify, recognize, and use their coping skills d. Suggesting to the extended family that prepared food would be helpful e. Recommending funeral homes in the community to the family f. Volunteering to watch the children while the adults attend the funeral

ANS: A, C While being an emotional support, bringing food, and volunteering to help with the funeral are all excellent community support tasks for a grieving family, the nurse's responsibility is more to help the family be aware of resources, including helping them ask for and be willing to accept help during the crisis period. In crisis, the nurse can help the family identify its typical coping behaviors and support or encourage their use. Although the other offers (such as baby-sitting) might be helpful, the nurse must remain more a consultant than a direct caregiver.

10. A nurse asked quite a few questions about what each family member did during the day, including school, work, and recreation outside the home. What was the nurse accomplishing by asking these questions? a. Assessing the community environment for possible community-wide problems b. Creating a picture of the family's relationships with outside agencies and resources c. Looking for topics the nurse might have in common with a family member d. Seeking an appropriate topic around which to establish rapport

ANS: B An eco-map can be used to help discover the interactions between the family and the outside environment. The family's relationships with significant community resources, activities, and agencies are diagrammed. It helps family members visualize how relationships with external systems are affecting their state of well-being.

23. Which of the following interventions would a nurse use to keep a family interaction focused on the problems that need to be resolved or improved? a. Clarifying the consequences if the problems are not resolved b. Emphasizing how many sessions the family may receive c. Stressing the seriousness of the problems that are confronting the family d. Demonstrating that there is no one else to help the family unless they act now

ANS: B Formulating a contract with the family at the beginning of the interaction, having a definite goal, and limiting the number of sessions help keep the interaction focused. It would not be therapeutic to suggest there are no other sources of help or that the problems are serious or have serious consequences (of which the family is probably already aware).

18. The teenage mother admitted to the nurse that sometimes she was sorry she had the baby, and all she wanted was to be able to sleep all night. Which of the following is the most appropriate action for the nurse to take? a. Ask the grandmother if she could take the baby for a few nights so the teenager could catch up on her sleep. b. Assure the mother that her feelings were normal and that no one likes being exhausted. c. Call Children's Protective Services as this mother is at high risk for child abuse. d. Explain normal growth and development for toddlers.

ANS: B It may help the mother to know that this situation is something all new mothers face and that her feelings are normal. Explaining normal growth and development for infants, not toddlers—including an expectation of when the baby might sleep through the night—would be most appropriate at this time. This would emphasize that the baby will eventually sleep through the night and the mother's sleep will no longer be interrupted. In other words, there is hope. Suggesting that the grandmother provide assistance may be helpful, but it will not allow the teenager to recognize that these feelings are normal. Calling Child Protective Services is not appropriate.

11. The nurse used multiple assessment tools to gather data on the family, which resulted in the nurse's feeling overwhelmed. What action should the nurse take next? a. Meet with the agency supervisor and review the data together. b. Summarize all the data into five or six categories. c. Talk to a colleague and share the information gathered. d. Work with the family at the next visit to draw conclusions.

ANS: B The information must be integrated and analyzed before decisions about the plan of care can be made. Once the information is summarized and targets of care are identified, the process of intervention is clearer for the nurse and the family. Asking others for input might be helpful, but the nurse is still the one who performed the observation and assessment and should be able to draw conclusions.

20. A community/public health nurse is working with a family whose members are experiencing an incredible amount of stress. Which source of social support should the nurse encourage the family to use? a. Family service workers from the agency b. Close friends and neighbors c. Family self-help groups d. Mental health counseling centers

ANS: B The nurse should first mobilize social support from inside the family or from informal support networks such as friends, neighbors, and religious communities with which the family was already involved. These relationships are more likely to be long lasting and to be the most culturally appropriate.

1. Why do community/public health nurses focus on families? a. Families will understand the higher cost of care if they are active participants. b. Improving the health of a family improves the health of a community. c. Nurses find such a focus much easier than trying to focus on the community. d. Nurses allow family members to receive respite by providing this type of care.

ANS: B When a nurse cares for a family, nursing practice is directed toward maximizing the health and well-being of all individuals within a family system. Improving the health of a family improves the health of a community.

15. After assessment and discussion with a family, a nurse had a list of 12 areas of need, none of which involved life-threatening issues. Which of the following needs should the nurse address first? a. The area in which the nurse is most expert b. The area the family wants to address first c. The area in which the nurse is most able to obtain resources to assist d. The area that matches the agency's current marketing plan

ANS: B When working with families, the need that assumes top priority (after life-threatening emergencies) is the need that the family itself identifies as most important.

3. A nurse was assessing the family style. Which of the following should be a priority for the nurse to assess? (Select all that apply.) a. Approach to accomplishing daily household tasks b. Characteristic processes used to process information and solve problems c. Consistent patterns of behavior over time d. Demonstrations of affection between family members e. Extent to which family is amenable or resistant to environmental factors f. Style of responding to emergency situations

ANS: B, C, D, E Family style refers to the ways the family usually acts to process information, solve problems, and open or close itself to the environment. Family style includes internal family interactions and relationships to the outside world, both of which remain fairly consistent over time. Other behaviors, such as how daily tasks are accomplished, are not part of family style.

8. The community/public health nurse asks a married couple to review important family events. What is the nurse accomplishing through this review? a. Giving the family members an opportunity to emote about negative events b. Recognizing how past events have changed their lives c. Providing an opportunity to review how they interact with each other d. Putting distance between past events and current reality

ANS: C A chronology, or time line, of family events is often useful in helping people see relationships between events and behavior changes. This allows the couple the opportunity to examine how they have interacted with each other during these events (their behavior and the associated event).

9. When a client's wife asked whether the nurse would like a tour of the yard and her gardens, the nurse agreed immediately. Considering the limited time the nurse had to spend with the family, why did the nurse agree to tour the gardens? a. Accepting the invitation encourages the wife to speak privately to the nurse. b. Completing the environmental assessment will assist with drawing a genogram. c. Examining of the environment helps identify potential health or safety problems. d. Touring the grounds allows the nurse to learn more about the family.

ANS: C Data about the family's physical environment, such as the presence of accident hazards, screens, plumbing, and cooking facilities, help the nurse (1) plan care that matches or supplements family resources and (2) identify potential health problems. The nurse may also be able to complete the other things suggested as responses; however, the main reason why the nurse is touring the garden is to identify potential hazards. An environmental assessment is not used for completing a genogram.

22. Two nurses were discussing a family that was undergoing two major crises simultaneously. The nurse assigned to the family decided to work on helping the family learn better coping mechanisms. The colleague asked why the nurse would try to create change when the family was under so much stress at the moment. Which of the following responses would be the most appropriate? a. "At the moment, I don't think the family will even notice I'm helping them change." b. "I'm only focusing on one person because if I can get one member to change, the others will change as well." c. "Now is when the family may recognize the need for change." d. "The family is under so much stress that one more stressor won't matter."

ANS: C Families have difficulty changing during times of crisis or stress. However, this period is often the best time to implement change because it is when the family sees the need for it.

12. A mother was very upset and said to a nurse, "My mother would never have allowed such behavior. I punish the baby for doing it, and she just does it again." What conclusion can the nurse make from this interaction? a. The family should be referred to community resources such as a daycare center. b. The infant may be developmentally delayed. c. The family needs assistance with growth and development education. d. The mother's actions need to be reported to children's protective services.

ANS: C Families meeting normal growth and developmental challenges often benefit from health-promotion and illness-prevention education or supportive contact as family members master behaviors appropriate for their new stage of life. Mothers cannot know appropriate childhood behaviors without an opportunity to know reasonable expectations according to the child's age and development. On the basis of the statement by the mother, it cannot be assumed that the mother is abusing her baby.

19. A family had just moved to the city when the illness struck the father. The wife had always been a stay-at-home mother with the three young children. The nurse developed a list of short-term resources for the family. Which of the following actions should the nurse take next? a. Give the family the complete list, including the free transportation assistance program. b. Involve the family with a local church where people could educate the family about the community and be supportive. c. Share with the family two resources that are the most immediate needs: namely, housing and food. d. Tell the family about all the resources and let the family decide what to do with the list.

ANS: C Many families have a need for multiple resources; identifying the one or two that are most helpful to the need will help both the nurse and the family. The entire list may well be overwhelming to the family when the family is already stressed and perhaps less able to make good decisions. Feeding the family and getting them settled will reduce their stress enough that they can then consider what would be most helpful.

5. A nurse met with a client before hospital discharge to make arrangements to visit the client at home. Why would the nurse visit the client's home when the assessment could be completed while the client is still in the hospital? a. The client may not realize all of the assistance that is needed until he or she returns home. b. The client needed time to consider the community resources that would be used in the future. c. The nurse wanted to include family and environmental conditions in the assessment. d. The nurse wanted to ask the client questions in a private setting.

ANS: C Meeting families in their own environment is preferable because the nurse can observe firsthand the physical and environmental conditions, as well as the way family members act with each other in their home.

4. A community/public health nurse is conducting a family assessment. Which source of data would be most helpful? a. Information from other cooperating health care agencies b. Input from other professional health care providers c. Observation and interaction with the family members d. Review of family members' charts and medical record data

ANS: C Sources of data can include, but should not be limited to, charts and written health records, biologic data such as blood pressure measurements or specimens, telephone calls and conversations with other health care team members, information from social service agencies involved with the family, and environmental and community information. However, the most accurate and complete information can be obtained only by observing and interviewing the family itself.

1. A community/public health nurse is creating a family map. Which of the following information would be included? (Select all that apply.) a. The address of the family and observations about the home and neighborhood b. All the family systems, including microsystems, macrosystems, and suprasystems c. Interaction patterns such as family coalitions or conflict between members d. Roles such as the family leader or the family communicator e. Hierarchies and power structures in the family f. The extended family for three generations, including marriages and births

ANS: C, D, E A family map is used to diagram spatial and relationship qualities of a family system to understand family hierarchies, roles, and power. Typically, such a map details the active patterns, such as coalitions, conflict, and avoidance.

6. A nurse left a home visit with a lengthy list of needs for which the family could use assistance. Which of these needs should be the priority for the nurse? (Select all that apply.) a. The area around the house was covered with trash hidden in the weeds. b. The teenage daughter did not have daycare for her 8-month-old son. c. The wife would not speak to her teenage daughter, who had recently had a child. d. The wife was having difficulty caring for her ill husband. e. The teenage daughter was not at all sure what to expect from her 8-month-old son. f. The husband had a stroke 2 years ago.

ANS: C, D, E Nurses help with growth and development issues, coping with losses and illness, adapting to the demands of or modifying the environment, strengthening inadequate resources and support, and dealing with disturbances in internal dynamics. The nurse as a teacher could help the teenage daughter understand normal growth and development of a very young child. As a counselor, the nurse could help the wife, who was having problems with the teenage daughter and the ill husband and seems to desperately need support. However, the husband's stroke is a chronic condition now inasmuch as it happened 2 years ago, and it does not take priority. The teenage daughter's not having daycare for her infant may cause additional stress for the family, but it would not be a priority for the nurse at this time.

5. What factors are involved in a nurse's decision as to which responsibilities can be accepted when a family's needs and desires are overwhelming? (Select all that apply.) a. External variables such as neighborhood environment b. Family's demands c. Nurse's competencies and preferences d. Only needs related to health e. Reimbursement rules f. Resources such as time and energy

ANS: C, E, F Families may make unreasonable demands of someone who might be able to help them, and often no human could meet what they request. Furthermore, the needs of the family may be beyond the scope of the nurse's competence or energy, and time and resources become a factor in making decisions about what a nurse can do. The agency and reimbursement mechanisms also dictate the nurse's role. A successful community/public health nurse will be aware of personal strengths and preferences and try to use them whenever possible. Because health is related to all aspects of life, excluding variables not related to health would not really exclude many family desires. External variables in the neighborhood are typically beyond the nurse's ability to repair.

3. What is the primary goal of case management of families? a. To ensure the care is given in the most cost-effective manner possible b. To coordinate all of the community agencies involved in care of the family c. To focus on communication, counseling, and teaching d. To work to maximize the family's self-care capabilities

ANS: D Although nurses try to be cost-effective and to communicate, counsel, or teach, as well as coordinate care, the ultimate goal of case management is to maximize the family's self-care capabilities.

13. After a family and a nurse discussed the family needs, they began to discuss what each member of the family might be willing to contribute. Which of the following would be the most important variable in determining the probable success of the plan? a. What is involved in the plan b. When the plan is scheduled to be implemented c. Where the plan will be implemented d. Who agreed to implementing the plan

ANS: D Because families act as systems, an action applied to one member will influence the other members. The most useful care plan will develop from the wishes of the family members who will be responsible for implementing it. However, every assessment should include identifying the most functional and most willing members because they will be the ones to follow through.

16. A community/public health nurse is providing care in the home of a family with children. The father returned from the physician during the nurse's visit and reported that the physician wanted several diagnostic tests performed. The father believed that the physician had looked quite serious. Which of the following actions would be most appropriate for the nurse? a. Assisting both parents with recognizing and meeting their children's needs b. Discussing illness management skills with the father and mother c. Sharing literature about hospice and family needs at the end of life d. Helping the family deal with anxiety and uncertainty

ANS: D Because the father is confronting a possibly serious illness, he is in the early phase of diagnosis, which necessitates preparation and cooperation with diagnostic testing. Both the father and the family as a whole will have to deal with anxiety and uncertainty. The nurse can help the family deal with anxiety and uncertainty by helping them to mobilize support while they await the diagnosis.

17. The father of a family was told he had metastatic pancreatic cancer too advanced for any treatment. Which of the following is the most appropriate intervention for the nurse? a. Assisting the family in finding a physician who can offer hope and possible treatment b. Helping the family deal with anxiety and uncertainty c. Sharing information about hospice and family needs at the end of life d. Trying to help the family find meaning in their situation

ANS: D Families who are dealing with illness and loss may encounter experiences in which nothing that they do will make the situation better. For example, a family may confront an irreversible loss, and no actions will rectify the situation. In these circumstances, both the nurse and the family often resolve the situation by searching for some meaning within what has happened.

6. A home health nurse was making an initial visit to an elderly man. As the nurse began the assessment, the man's wife gave all of the information requested. Which of the following actions should the nurse take next? a. Agreeing on appropriate interventions with the family b. Determining appropriate nursing diagnoses c. Assessing the environment of the wider community d. Confirming the information with the client

ANS: D Having heard from only the wife, the nurse must attempt to validate the information with the husband or recognize that all information was from only one perspective.

21. The nurse has suggested that a family make several changes to make the care for their technology-dependent child easier, more effective, and even faster. However, the family took no action. Which of the following would explain the lack of response by the family? a. The family did not like the nurse's suggestions but were too polite to tell the nurse. b. The family did not really understand the nurse's suggestions. c. The family lacked the resources necessary to implement the nurse's suggestions. d. All families have a tendency to resist change, even if it is helpful.

ANS: D People have a tendency to want to stay the same, and so families usually resist change even if the change would be a helpful one. The nurse must help the family decide what they want to do.

24. Which of the following actions best demonstrates the use of summative evaluation? a. Explaining the goals of blood glucose control and the diabetic diet plan b. Asking a diabetic client what he ate for the last three meals to see whether it fits the diet plan c. Reviewing the daily blood glucose levels each week with a diabetic client d. Quizzing a diabetic client about his current diabetic medications before discharge

ANS: D Summative evaluation is performed after the care is complete and the nurse-family interaction is terminated. This is best demonstrated by quizzing a client about diabetic medications before discharge. Formative evaluation is performed as care is being given during the course of the family-nurse interaction to see whether instructions are understood and the plan is effective. Asking about understanding, eating habits, and reviewing blood glucose levels weekly are examples of formative evaluation.

7. A nurse is assigned to care for a client who has just been discharged from the hospital. What should be the nurse's priority assessment after discovering that other family members desperately need health care as well? a. Focusing on identified problems and the person with the most problems b. Reviewing the home and the immediate environment for external problems c. Interviewing the family members to get an overall picture of family functioning d. Providing care for the client who has been discharged from the hospital

ANS: D Typically, one member of the family is identified as the client who is to be the recipient of nursing care. This client may have an identified health problem, a chronic illness, or a potential problem. Adequate identification and collection of information about the client's response to these actual or potential health problems is the first priority in family assessment.