Chapter 12: Interprofessional Collaborative Practice and Care Coordination Across Settings

The home care nurse asks the client and family about their socioeconomic status, culture, and beliefs. Which is the best response by the nurse when the family asks why those questions are being asked? -"I want to understand what your desires are." -"I am trying to build a relationship with you." -"I need this information for billing purposes." -"I have to ask because it is required in every referral to home care."

"I want to understand what your desires are." Explanation: During the assessment phase of a home care visit, the nurse collects subjective information on how the client normally manages at home, what the home is like, and what family and community support is available. The nurse explores the client's beliefs and culture, competencies, capabilities, concerns, deficits, and limitations to understand how the client manages at home and what the client desires. Nursing diagnoses, outcome criteria, and implementation occur later in the nursing process and are based on the assessment data. Building relationships with clients are important, but this question is specifically aimed at understanding what the client desires. This information is not needed for billing purposes. The client has the right to refuse to answer any question. While some questions may be needed upon initial assessment after referral, this is not the best response.

A home health client requires intravenous (IV) antibiotics every 4 hours. The client's spouse asks to be taught how to administer the medication. Which nursing response is indicated? -"Since the medication is IV, it must be given by a nurse." -"Let me teach you how to give this medication." -"It will be better if a medication aide comes by to give the medication." -"We will need special permission from the company for you to give the medication."

"Let me teach you how to give this medication." Explanation: Family members or other caregivers may be taught any skill that they are able and willing to perform. The nurse should teach the spouse, making certain to see a return demonstration of technique. IV infusions do not require special permission for medications to be given by family members, as long as family is taught. The medical supply company does not provide permission for the administration of the medication. The nurse provides the family and client teaching, not an aide.

A nurse has been asked to chair an action team tasked with prioritizing a list of possible new equipment purchases. Which statements, made by this nurse, will help the team be most effective? Select all that apply. -"When I got this assignment, they said something about deciding what equipment to purchase next year." -"I am willing to prioritize the list if someone else will write the rationale." -"Once we have completed the list and rationale, I will compile our recommendations for us all to sign before submission." -"Before our next meeting, each of us will ask the nurses on the unit what their priority purchase would be." -"Our goal is to prioritize this list of potential equipment purchases, offering rationale for our choices."

"Our goal is to prioritize this list of potential equipment purchases, offering rationale for our choices." "Before our next meeting, each of us will ask the nurses on the unit what their priority purchase would be." "Once we have completed the list and rationale, I will compile our recommendations for us all to sign before submission." Explanation: The most important component of team structure is to have a common goal. The goal of this group is to list potential equipment purchases with rationale. The second-most important component of team structure is to have clear roles and responsibilities. The direction by the nurse for the members to query nurses on each unit is an example of establishing clear roles and responsibilities. Teams also should hold themselves mutually accountable for achieving the goal, such as by having all the team members sign the recommendation. The work should be done by the team, not by just one or two members, as in the option about one nurse prioritizing the list and another writing rationale. Clarity and specificity are important in communicating the purpose of the team, both of which are lacking in the statement, "they said something about deciding what equipment to purchase next year."

A home health care nurse is explaining to an emergency room nurse how nursing care in the home setting differs from that in the hospital setting. Which statement by the home health care nurse would be most appropriate? -"The client and family are in control of the setting, not the nurse." -"Each team member works independently of other team members." -"You need a graduate degree to specialize in home health care." -"It requires that you have high-level critical care skills."

"The client and family are in control of the setting, not the nurse." Explanation: In home health care, the nurse is a "guest" in the client's home. Thus, the client and family retain the power and control that they normally relinquish to providers in other settings, such as an acute care facility. A generalist background and focus are useful, as well as broad assessment skills and a knowledge base to provide clients with appropriate education that will keep them as independent as possible. A graduate degree or high-level critical care skills are not necessary. Collaboration among team members is essential.

A nurse is using the SBAR approach for handoff communication when transferring a client to the critical care unit. Which statement would the nurse include as part of the recommendation? -"The client had an exploratory laparotomy 2 days ago and was progressing well. The vital signs were stable until this episode." -"The client is scheduled for a cardiac catheterization in about an hour and needs monitoring every 15 minutes." -"This event seemed to come out of the blue. The client denies any history of heart disease but does take a baby aspirin each night." -"The client began complaining of severe chest pain, rating it as a 10 on a scale of 1 to 10, after walking back from the bathroom."

"The client is scheduled for a cardiac catheterization in about an hour and needs monitoring every 15 minutes." Explanation: SBAR provides a framework for communication between members of the health care team about a client's condition. It is an easy and focused way to set expectations for what will be communicated between members of the team, which is essential for developing teamwork and fostering a culture of client safety. S stands for the situation (complaint, diagnosis, treatment plan, and client's wants and needs); B stands for background (vital signs, mental and code status, list of medications, and lab results); A stands for assessment (current provider's assessment of the situation); and R stands for recommendations (identification of pending lab results and what needs to be done over the next few hours, along with other recommendations for care).

Which circumstance likely requires the most documentation and communication on the part of the nurse? -A client is being discharged home following a laparoscopic appendectomy 2 days earlier. -A geriatric client is being transferred from a subacute medical unit to a new long-term care facility following recovery from pneumonia. -A client is being transferred from one medical unit of the hospital to another to accommodate a client on isolation precautions. -A client is returning to an assisted-living facility following a colonoscopy earlier that day.

A geriatric client is being transferred from a subacute medical unit to a new long-term care facility following recovery from pneumonia. Explanation: Transfer from the hospital setting to a long-term care facility is likely to require significant documentation and communication from the nurse facilitating the transfer. This may include copying the chart or summarizing a large amount of relevant data. Transfers within a hospital typically require somewhat less documentation and communication, and discharges home or to an existing facility may not require a formal report of any type.

A nurse is covering all aspects of admission procedures for a client who is receiving home health services. The nurse explains what procedures will be covered during the nurse's visits. Which aspect of the admission process does this represent? -Assisting in participation of the care-related decisions -Clearly defining the purpose and expectations of the admission -Documenting the procedure -Establishing rapport and showing willingness to listen

Clearly defining the purpose and expectations of the admission Explanation: During the admission to the health care system, the nurse should clearly explain to the client the purpose and expectations of admission, such as what procedures will be covered. Explaining what procedures will be covered does not pertain to establishing rapport with the client, documenting a procedure, or helping the client participate in care-related decisions.

A nurse is assisting with the transfer of a client from the acute care facility to the rehabilitation facility for continued care. Which skill would be most important for the nurse to use to promote continuity of care? -Care planning -Assessment -Documentation -Communication

Communication Explanation: Although assessment, documentation, and care-planning skills are important, continuity depends on excellent communication as clients move from one caregiver or health care site to another. Too often, breakdowns in communication among caregivers result in medical errors or deficient plans of care.

The nterm-11urse is assessing the birth rates and death rates of the local municipality and comparing these rates to those of the nation and the world. Which type of nursing is this nurse practicing? -Community health nursing -Home health nursing -Parish nursing -Research nursing

Community health nursing Explanation: Examining birth rates and death rates of a community is the focus of community health nursing, also known as public health nursing. Community health nursing focuses on the health of populations in the community. Research nursing is more comprehensive than just the gathering of data and would involve analyzing the data obtained. Home health nursing focuses on the care of the individual client and family in the home environment, performing a skilled nursing service as a registered nurse. Parish nursing is a form of community health nursing but does not include the gathering of data regarding populations.

Which action must the nurse perform on discharge of a client from an acute care facility? -Writing any orders for future home visits that may be necessary for the client -Writing a discharge order for the client -Coordinating future care for the client -Sending the client's records to the attending health care provider

Coordinating future care for the client Explanation: Coordinating future care is a means for providing continuity of care so that the client and family needs are consistently met as the client moves from a care setting to home. The health care provider, not the nurse, writes the discharge order for the client, as well as any orders needed for future home visits. Sending the client's records to the attending health care provider is not necessary unless the health care provider asks for certain records to be sent to the health care provider's office.

A successful discharge includes effective planning. Identifying and meeting client needs beyond the acute care facility reduce readmissions. Which nursing role is of great importance to this success? -Caregiver -Nurse practitioner -Clinician -Coordinator

Coordinator Explanation: Discharge planning is most successful when it is done in collaboration with the client and family, not for them. The discharge planner or coordinator is the health or social services professional who is responsible for coordinating the transition and serving as a link between the discharging facility and the community. A nurse practitioner is an advanced clinician who prescribes medications and provides care. A clinician is a health care provider having direct contact with and responsibility for clients. A caregiver is a family member or paid helper who regularly looks after a child or a person who is sick, older, or disabled.

In anticipation of discharge, a nurse is teaching the daughter of an older adult client how to change the dressing on the client's venous ulcer. Which teaching strategy is most likely to be effective? -Use a multimedia strategy that combines animation with narration. -Demonstrate and explain the procedure and then have the daughter perform it. -Provide explicit written and verbal instructions and ask the daughter to explain back to the nurse how to perform the procedure. -Explain the procedure clearly and slowly while providing multiple opportunities for the daughter to ask questions.

Demonstrate and explain the procedure and then have the daughter perform it. Explanation: All steps of a procedure such as a dressing change should be demonstrated, practiced, and provided in writing. The client or caregiver should then perform the procedure or treatment in the presence of the nurse to demonstrate understanding and ability to carry out the procedure. This is more likely to facilitate success than providing a passive multimedia resource, explaining, or providing written instructions alone without reciprocal demonstration.

The nursing student asks the home health nurse what data is required for a Medicare home plan of care. Which item would be incorrect for the nurse to include when responding to the student? -Types of services and equipment required -Functional limitations -Medications and treatments -Documented need for a speech pathologist

Documented need for a speech pathologist Explanation: A documented need for a speech pathologist is not required for a Medicare home plan of care. Required data would include types of services and equipment required, functional limitations of the client, and ordered medications and treatments.

The nurse is working with a client's family and social worker to select a home health care agency. Which question does the nurse state should be the family's priority when interviewing potential home health agencies? -Is the facility listed as a government-approved facility with no infractions? -Does the agency provide care to facilitate transition to a hospital? -How does the agency train employees for accountability and do they require a background check? -Does the agency meet uniform standards for licensing, certification, and accreditation by state agencies and/or federal programs?

Does the agency meet uniform standards for licensing, certification, and accreditation by state agencies and/or federal programs? Explanation: The most important information a family should obtain before selecting a home health agency is determining whether the agency meets uniform standards for licensing, certification, and accreditation. Inquiring about infractions listed with government organizations is important but would not be a family's priority question. Home health agencies facilitate transition from hospital to home, not home to hospital. Home care agencies typically require background checks and conduct training of employees. While these requirements can and should be confirmed by the family, it is not the most important information to obtain.

A registered nurse is providing community-based health care for a client diagnosed with early onset dementia. Which strategy is best for the nurse to employ to facilitate the family participating in the client's care? -Create a care plan based on the client's requests and inform the family of the client's wishes. -Encourage active participation of the client and family in health care decisions. -Reinforce the care plan to the family if it is determined the client is not properly cared for. -Provide referrals for health care professionals to perform the client's activities of daily living (ADLs).

Encourage active participation of the client and family in health care decisions. Explanation: In a community-based health care setting, the nurse should involve the client and the family in all health care decisions for the client. The nature of the relationship is that of a partnership based on respect, appreciation, and cooperation. Reinforcing to the family that the client is not well-cared for should be done, but it is more important to involve the client and family in the care. The client and family should be encouraged to provide ADLs as they are able. Client care decisions should be made in conjunction with the family, and the family should be encouraged to participate in those decisions. The client's plan of care should include input from the family.

Which is the primary goal of continuity of care? -Increasing clients' knowledge base and improving their health maintenance behaviors -Controlling costs and maximizing client outcomes after discharge from the hospital -Minimizing nurses' legal liability during client transitions between health care institutions -Ensuring a smooth and safe transition between different health care settings

Ensuring a smooth and safe transition between different health care settings Explanation: Continuity of care exists to ensure smooth and safe transitions for clients when moving from one health care setting to another. This requires that all providers involved in the client's care effectively communicate the client's health information among themselves so that the client may maximize recovery and health. The primary goal of continuity of care is not to build the client's knowledge base or improve health maintenance behaviors, minimize the nurse's legal liability, or control health care costs.

Which interventions would be performed by the occupational therapist as a member of the home health care team? Select all that apply. -Provide assistance with securing needed equipment. -Implement the plan of care designed by the nurse. -Teach the client about strengthening exercises. -Educate the client and family about promoting self-care in activities of daily living. -Evaluate the client's functional level.

Evaluate the client's functional level. Teach the client about strengthening exercises. Educate the client and family about promoting self-care in activities of daily living. Provide assistance with securing needed equipment. Explanation: The occupational therapist evaluates the client's functional level and educates the client and family on promoting self-care in activities of daily living. The occupational therapist may teach about strengthening exercises and help secure equipment, as needed. The home health aide, not the occupational therapist, implements the plan of care designed by the nurse.

A new client arrived on the unit while the nurse was obtaining the end-of-shift report from the night nurse. This client is admitted walking and is here for a cardiac workup; the client is assigned to the nurse. The unlicensed assistive personnel has settled the client in the room and oriented the client to the surroundings, call system, bathroom, bedside supplies, and where to place clothes. Which is the nurse's priority action? -Call the dietary department to get breakfast for the client. -Ask the unlicensed assistive personnel to obtain vital signs. -Gather information and complete the admission database. -Obtain the health care provider's orders.

Gather information and complete the admission database. Explanation: The nurse's priority is to complete the admission of the client and perform the history, assessment, and documentation. Additional interventions that can be completed after the assessment include asking the unlicensed assistive personnel to obtain vital signs, retrieving the admission orders from the health care provider, and following up with dietary if warranted.

The nurse is planning discharge of the client who had surgery for a left hip replacement. The client is being discharged from the hospital to the home and requires home medical services. Which item would be provided by home medical services? -Homemaking -Intravenous therapy -High-rise toilet seat -Pain management

High-rise toilet seat Explanation: Home medical services provide durable medical equipment, such as walkers, canes, crutches, wheelchairs, high-rise toilet seats, commodes, beds, and oxygen. Custodial services include homemaking and housekeeping services, as well as companionship and live-in services. Hospice services provide pain management, health care provider services, spiritual support, respite care, and bereavement counseling. High-technology pharmacology services provide intravenous therapy, home uterine monitoring, ventilator management, and chemotherapy.

Which are community-based settings? Select all that apply. -Schools -Nursing homes -Workplaces -Homes -Hospitals

Homes Schools Workplaces Explanation: A nurse desiring to work in a community-based setting can work in homes, schools, or workplaces. Hospitals and nursing homes are not community-based settings. These are institutional settings for nursing practice.

A nurse is caring for a 17-year-old pregnant client who is unable to afford health care. Which resources will the nurse access to obtain assistance for this client? -Suggest asking a family member for monetary assistance. -Call the local welfare agency to see if the client qualifies for services. -Tell the client that better management of money is required to care for infants. -Make a referral to the social services department.

Make a referral to the social services department. Explanation: The client should be referred to social services, as social workers are educated to assist clients in such situations. Calling the local welfare agency is not a good use of resources, as social services will review all pertinent client needs and connect the client with the appropriate resources. Telling the client to manage money better is belittling and not helping the client in managing the difficult situation. Suggesting to ask family members for assistance is assuming it has not been done or that the client is incapable of helping with the situation.

Home health care nurses are required to complete the Outcome and Assessment Information Set (OASIS) by which entity? -Any third-party payer -Medicaid -Any insurance company -Medicare

Medicare Explanation: OASIS provides standardized guidelines for admission and care, as well as a national database for evaluation, reimbursement, and quality improvement. The OASIS system of data collection is required by Medicare, not by Medicaid, insurance companies, or any other third-party payer.

A home health nurse uses different professional skills to achieve a successful care plan for clients in their home setting. Which skill is of most importance to the nurse? -Comprehensive health assessment -Knowledge of the regulations and policies of the home health care set-up -Social connections to facilitate meeting the client's needs -Nurse-client rapport

Nurse-client rapport Explanation: A key to successful care management in the home setting is the quality of the nurse-client relationship in the context of the client's family and community. In partnership with clients, the nurse facilitates individuals' abilities to accomplish health and self-care goals. The other answers represent skills that would be useful for meeting other goals but not as useful as the nurse-client rapport for managing the client's overall care. Knowing the policies and regulations would facilitate an understanding of what care equipment and services are available to the client. A comprehensive assessment provides assessment data to support the development of a plan of care. Social connections would facilitate social interactions for a client diagnosed with social isolation.

The home care nurse is providing care and education to a client who is pregnant for the first time. The client states, "I have no money or food. I don't know what I should do. I want to provide for my unborn child." The nurse refers the woman to the WIC program and a local food bank. This is an example of what aspect of community-based nursing? -Planning -Evaluation -Assessment -Restoration

Planning Explanation: Planning and intervention focus on using individual, family, and community resources to assist in restoring a client's health to maximum possible functioning, while continuing to monitor for possible side effects or complications to treatment. Assessment involves determining the client's care needs. Restoration involves helping a client regain a former level of functioning after an injury or other debilitating health event. Evaluation involves determining the effectiveness of a care plan after it has been implemented.

What is the priority nursing responsibility when transferring a client from one unit in the hospital to another? -Transport the completed client chart to the receiving unit. -Provide a verbal report of the client's status to the admitting nurse. -Bring all of the client's belongings to the new unit. -Help the client become familiar with the new unit.

Provide a verbal report of the client's status to the admitting nurse. Explanation: Although the nurse may transport belongings and the chart, the priority responsibility for the nurse is the verbal report/communication with the nurse on the new unit. It is not the task of the nurse who brings the client to the new unit to orient the client.

A client with severe congestive heart failure (CHF) has been referred to a long-term care facility. The nurse is transferring care from the hospital setting to a long-term care facility. Which action is a priority to ensure continuity of care for this client? -Asking family members to meet with the social worker at the receiving facility prior to the client's arrival. -Notifying all departments of the room change. -Discussing the move with both client and the family. -Providing accurate and complete communication to the new facility.

Providing accurate and complete communication to the new facility. Explanation: To ensure continuity of care for the client, the nurse should send a detailed assessment and care plan from the hospital to the extended care facility. Frequently, the nurse at the hospital provides a verbal report to the nurse at the new facility using the approved handoff technique. Other departments at the hospital should be notified of the client's discharge, but this does not affect the client's continuity of care. Discussing the move with the client and family is important, but this does not ensure continuity of care. The family members are asked to meet with the social worker but, again, this does not ensure continuity of care.

In preparation for discharge, the nurse is reviewing information related to new dietary guidelines with the client. This is an example of which step in discharge planning? -Developing goals with the client -Assessing the client's needs and identifying problems -Providing client education -Making home health care referrals

Providing client education Explanation: The nurse is teaching the client important information about self-care at home prior to the client's discharge. The initial step in discharge planning is collecting and organizing data about the client, as this provides information on the client's health care needs. Home referrals may be made after the education process, based on orders provided by the health care provider. Developing goals may occur after the education process, as the goals need to be realistic.

In preparation for discharge, the nurse is reviewing information related to new dietary guidelines with the client. This is an example of which step in discharge planning? -Assessing the client's needs and identifying problems -Providing client education -Making home health care referrals -Developing goals with the client

Providing client education Explanation: The nurse is teaching the client important information about self-care at home prior to the client's discharge. The initial step in discharge planning is collecting and organizing data about the client, as this provides information on the client's health care needs. Home referrals may be made after the education process, based on orders provided by the health care provider. Developing goals may occur after the education process, as the goals need to be realistic.

A client diagnosed with terminal leukemia is receiving home health care services to assist in the client's care. After assessing the client, the home health care nurse determines that the client is unable to afford needed medical supplies. Which is the best strategy for the nurse to implement to assist the client? -Enlist the services of the client's family for some components of care, such as dressing changes and physical therapy. -Discuss the client situation with the provider for possible therapies that are more cost-conscious. -Refer the client to a local religious organization or non-profit agency for support. -Refer the client to a social worker to determine eligibility for assistance.

Refer the client to a social worker to determine eligibility for assistance. Explanation: Social workers assist in finding and connecting the client with community resources or financial resources and provide counseling and support. A social worker is better equipped to find community resources or financial resources than a health care provider. Discussing alternative therapies with the provider may be beneficial, but typically this does not apply to some medical supplies that the client needs. Likewise, having the client's family participate in dressing changes is helpful, but will not particularly offset certain medical supplies that may be needed. Local non-profit organizations and religious organizations may be able to offer some assistance, but a social worker would be the best person to find resources and make referrals.

The client is being discharged to the home setting following a stroke. Which activity would the occupational therapist assist the client with? -Improving oral communication -Relearning how to cook safely -Gait training with a walker -Improving the ability to swallow

Relearning how to cook safely Explanation: The occupational therapist can evaluate the functional level of the client and teach activities to promote self-care in activities of daily living, such as cooking. The physical therapist provides direct care, such as muscle-strengthening exercises, gait training, and massage. The speech therapist assists with speech and language ability, as well as eating and swallowing.

Which qualities are essential for a community-based nurse? Select all that apply. -Keen physical assessment skills -Effective communication skills -Competence in assisting with minor surgical procedures -Ability to delegate client care tasks to unlicensed assistive personnel -Strong knowledge foundation

Strong knowledge foundation Effective communication skills Keen physical assessment skills Explanation: Community-based nurses must possess several key qualities: they must be knowledgeable and skilled in their practice (including strong and effective communication and physical assessment skills), able to make decisions independently, and willing to remain accountable. They are less likely need skills in delegating client care or assisting with minor surgical procedures, as the nurse will typically work alone and as surgical procedures are not performed in the home care setting.

An 82-year-old client is being discharged from the hospital following a bowel resection. The client lives alone and the client's family is out of town. Which factor will have the greatest effect on the client's home care management? -Transportation -Support system -Medication management -Psychosocial needs

Support system Explanation: A client who has had bowel surgery, particularly an older client, would require much assistance in performing activities of daily living while recovering. Because this client lives alone and has no family available, the client may not be able to stay at home and may need to be placed in a facility to provide adequate support. A strong support system could meet the client's needs for medication management, transportation, and psychosocial support. A lack of a support system would likely mean that none of these other needs would be met. Thus, the client's support system is the most important factor related to home care management.

A hospital has begun to expand home health services to its clients. Which reason is the most likely cause for the expansion of these services? -The need for decreased financial expenditures -Changes to the structure of Medicare and Medicaid -The change to shorter hospital stays -The increase in the incidence and prevalence of infectious diseases

The change to shorter hospital stays Explanation: Decreased hospital stays have led to an increase in community-based health care services, including home health services. This phenomenon has not been directly linked to structural changes in Medicare or Medicaid, financial considerations, or changes in disease patterns.

A client is receiving home health services after having a stroke and being hospitalized. After a thorough assessment of the home environment and the client, what would indicate to the nurse that there is an impairment in the client's home management? -The client refuses to allow the caregiver to help the client sit up in bed. -The client reports having slipped in the restroom the first night in the hospital. -The home care nurse has to reschedule an appointment with the client. -The client's caregiver is absent whenever the nurse visits and the client is alone.

The client's caregiver is absent whenever the nurse visits and the client is alone. Explanation: The nurse determines that there is an impairment in home management when the caregiver is not present to provide care to the client as well as answer questions regarding the care of the client. Education should be able to be provided to the client and caregiver. The nurse having to reschedule an appointment may occur for any number of reasons, but the client should have support in the home even if the nurse is unable to be there. Refusal of care does not indicate home management impairment. Slipping in the hospital environment has no bearing on home management.

The nurse is preparing to begin the discharge planning process with a client whose pulmonary embolism has recently resolved. Which factor should the nurse prioritize during this process? -The nurse's knowledge base and experience level -The NANDA diagnoses relevant to the client's condition -The client's potential for recurrence -The client's identified needs and goals

The client's identified needs and goals Explanation: The central focus of client teaching and the larger discharge planning process should be the identified health care needs of the client and the goals that the client identifies or acknowledges. The nurse's skills and knowledge, the client's potential for recurrence, and the relevant NANDA nursing diagnoses are all elements that may inform the discharge planning process, but they are superseded by the client's goals and expressed needs.

One of the fastest growing venues of practice for the nurse is home health care. What is the basis for the growth in this health care setting? -The preference of nurses to work during the day instead of evening or night shifts -The focus on treatment of disease -The discharge home of clients who are more critically ill -The chronic nursing shortage

The discharge home of clients who are more critically ill Explanation: With shorter hospital stays and increased use of outpatient health care services, more clients who are critically ill require nursing care in the home and community setting. The other answers are incorrect because they are not the basis for the growth in nursing care delivered in the home setting. The chronic nursing shortage and the focus on the treatment of disease do not affect the growth in home health care, because both of these factors have no more or less of an effect on home health care than they do care provided in an acute care facility. Nurses, as a whole, do not necessarily prefer to work during the day rather than at night; some prefer to work in the day and some prefer to work at night. In any case, nurses work both day and night shifts in home health care just as in an acute care facility.

Which member of the health care team is most often responsible for providing the order that will begin a client's course of home health care? -The hospital discharge planner -The registered nurse -The health care provider -The case manager

The health care provider Explanation: Although referrals for home health care may originate from a variety of professions, the order that is required for care to proceed is provided by the health care provider or, in some cases, a nurse practitioner. Case managers, registered nurses, and hospital discharge planners do not have the authority to issues such an order.

A nurse is using the ISBARQ (introduction, situation, background, assessment, recommendation, and question and answer) framework for handoff communication. Which examples accurately represent this process? Select all that apply. -The nurse introduces the client to the health care professionals who will be involved in the new facility. -The nurse reports the client's vital signs, mental and code status, medications, and lab results. -The nurse makes arrangements for future home health care visits for the client who is being discharged from the hospital. -The nurse explains the client's chief complaint, diagnosis, treatment plan, and wants/needs. -The individuals involved in the process identify themselves, their roles, and their jobs. -The nurse reports the current provider's assessment of the client and need for further services.

The individuals involved in the process identify themselves, their roles, and their jobs. The nurse reports the client's vital signs, mental and code status, medications, and lab results. The nurse explains the client's chief complaint, diagnosis, treatment plan, and wants/needs. The nurse reports the current provider's assessment of the client and need for further services. Explanation: ISBARQ provides a framework for communication between members of the health care team about a client's condition. It is an easy and focused way to set expectations for what will be communicated and how communication will occur between members of the health care team. Introduction refers to those involved in the client handoff identifying themselves, their roles, and their jobs. Background includes the client's vital signs, mental and code status, medications, and lab results. Situation includes the client's chief complaint, diagnosis, treatment plan, and client wants and needs. Assessment includes the nurse reporting the current provider's assessment of the client and need for further services. Introduction of the client and making arrangements for home care are not included in handoff communication.

A nurse is admitting a client to a hospital. Which actions should the nurse perform initially upon this admission? Select all that apply. -The nurse gives the client a form explaining the Patient Care Partnership. -The nurse obtains client information, which is printed on an admission sheet and becomes part of the client's permanent record. -The nurse asks the client about existing advance directives; if none, the nurse gives the appropriate form to the client. -The nurse clearly describes how the client information will be used and disclosed to other parties. -The nurse asks the client to sign consent forms allowing treatment and the hospital to contact insurance companies as needed. -The nurse makes sure the client's name and address and the name of the closest relative are printed on an identification bracelet.

The nurse asks the client to sign consent forms allowing treatment and the hospital to contact insurance companies as needed. The nurse obtains client information, which is printed on an admission sheet and becomes part of the client's permanent record. The nurse asks the client about existing advance directives; if none, the nurse gives the appropriate form to the client. The nurse clearly describes how the client information will be used and disclosed to other parties. The nurse gives the client a form explaining the Patient Care Partnership. Explanation: The nurse asks the client to sign a consent form for general care, as well as a form that allows the facility to contact insurance companies for reimbursement of care provided. The nurse obtains client information, such as emergency contacts, on admission, which becomes a permanent part of the client's record. The nurse addresses advance directives during admission, offering the client the opportunity to complete one if desired. The nurse discusses privacy information, such as designating family members who may be given health status information, and has the client sign a privacy form. The nurse discusses with the client the Patient Care Partnership, which addresses the client's rights, and provides a form explaining these rights. The identification number (often included as a barcode), as well as the client's name and health care provider's name, are typical items found on the identification bracelet, not the client's address or the name of the closest relative.

It is important for home health care nurses to remember which point? -The nurse is the guest in the client's home. -Rehabilitation is the major client goal. -The nurse should act as a counselor and advisor. -The nurse is the primary caregiver.

The nurse is the guest in the client's home. Explanation: An essential difference in home care versus acute care is that the home care nurse is a guest in the client's home. Family or other support persons are the primary caregivers, rehabilitation may not be the goal, and the nurse does not typically act as a counselor or advisor.

A nurse is preparing for handoff communication for a client who is being discharged from the hospital to home health care. Which example is not an action performed during this process? -The nurse uses the SBAR technique during the handoff. -The nurse asks the other health care professionals if they have any questions. -The nurse determines who should be involved in the handoff communication. -The nurse prepares the new room for the client.

The nurse prepares the new room for the client. Explanation: The nurse prepares the new room for a client prior to admission, not during the discharge process. The client handoff refers to transferring responsibility for a client from one caregiver to another with the goal of providing timely, accurate information about a client's plan of care, treatment, current condition and anticipated changes. The nurse determines who she needs to communicate with during the discharge and asks those health care professionals if they have any questions in order to provide continuity of care. SBAR (Situation-Background-Assessment-Recommendation) is an outline that many facilities follow to ensure that proper communication occurs during the handoff procedure.

When a multidisciplinary team is involved in meeting the home care needs of a client, who is the person responsible for the coordination of the care provided? -The home health care aide -The chaplain or minister -The social worker -The registered nurse

The registered nurse Explanation: Regardless of the number of providers for home health care, the responsibility for care coordination remains with the registered nurse, not with the social worker, chaplain or minister, or home health care aide.

When would it be appropriate for the nurse to initiate discharge planning with a client who will be discharged the next morning? -When providing preoperative education related to a scheduled cataract extraction -During chest radiography -When the client is being triaged -When the client is signing consent forms

When providing preoperative education related to a scheduled cataract extraction Explanation: Discharge planning prepares a client to move from one level of care to another within or outside of the current health care facility. Traditionally, this process involved discharge from the hospital to the home. In the current health care system, discharge planning occurs in all settings, including ambulatory surgical centers, rehabilitation units, drug treatment centers, and childbirth centers. A chest radiograph is used to diagnose a client's problem; thus, it would be premature to initiate discharge planning at this time, as too little is known about the client's condition, needed course of treatment, prognosis, and care needs following discharge. Similarly, clients are triaged before they are admitted to a health care facility, so it would be premature to initiate discharge planning before the client's condition is even known and before it is clear whether the client will even need to be admitted. Clients sign consent forms during the admission process, which clearly would be an inappropriate time to initiate discharge planning.

The nurse understands that planning for discharge actually begins at admission to the facility. The purpose of discharge planning is best described as: -promoting less dependence on others. -providing continuity of care that is goal directed. -decreasing stress for client and family members. -ensuring client safety and health maintenance.

providing continuity of care that is goal directed. Explanation: The purpose of discharge planning is to provide for continuity of care so that the needs of the client and family are consistently met as the client goes from hospital to home. The others may be additional goals.

The initial step in discharge planning is: -collecting and organizing data about the client. -establishing goals with the client. -providing home health care referrals. -teaching the client self-care activities that are to be conducted in the home setting.

collecting and organizing data about the client. Explanation: The initial step in discharge planning is collecting and organizing data about the client, as this provides information on the client's health care needs. Establishing goals, client teaching, and providing home health care referrals are steps that follow the collection and organization of data.

Continuity of care is an important concept for quality nursing practice. The responsible nurse understands the best description of the process of continuity of care is to: -assist the client to focus on health goals and reach outcomes. -coordinate uninterrupted care and facilitate transfer between units and levels of care. -teach the client self-care regarding medications and plan of care. -manage the individual care needs of the client throughout the hospital stay.

coordinate uninterrupted care and facilitate transfer between units and levels of care. Explanation: The most comprehensive description of continuity of care is appropriate, uninterrupted care that facilitates transfer of the client between settings and levels of care. The others address specific needs/goals of the client, but do not describe coordination of care that provides for consistency and continuity.

A home health care nurse develops a client's individualized plan of care during the: -referral process. -pre-entry phase. -entry phase. -discharge planning.

entry phase. Explanation: Nurses provide home health care interventions during the entry phase, using an individualized plan of care for each client based initially on identifying individualized health care needs. In the entry phase, the nurse develops rapport with the client and family, makes assessments, determines nursing diagnoses, establishes desired outcomes (along with the client and family), plans and implements prescribed care, and provides teaching. During the pre-entry phase, which includes the referral process, the provider or discharge planner of a hospital contacts the home care facility and provides a brief medical history, along with indications for home health services, and then the referral nurse at the home care facility collects as much information as possible about the client's diagnoses, surgical experience, socioeconomic status, and treatments ordered. Discharge planning occurs during the pre-entry phase and would be too soon for creating a client's individualized plan of home health care, as the home health nurse still needs to meet and assess the client and family first.

Continuity of care for a particular client is most important to prevent: -fragmentation of services. -infection. -rising health care costs. -multiple providers.

fragmentation of services. Explanation: Continuity of care is the provision of health care services without disruption, regardless of movement between settings. It is most important in preventing fragmentation of health care services. It does not prevent a client from needing the services of multiple providers, although it can ensure better communication and coordination among these providers, resulting in improved outcomes for the client. Continuity of care would not directly prevent infection, but in preventing fragmentation of care, it could indirectly help prevent infection. Ensuring continuity of care for a single client would not help prevent rising health care costs, in general, although it could help lower some costs for the individual client by reducing redundancy.

When educating clients in the community on health promotion and prevention of disease, it is important to stress: -health education can benefit individuals and groups. -health promotion may not be possible for many of the older members of a community. -the ideal location for education is in a health care institution. -strenuous exercise is necessary for health.

health education can benefit individuals and groups. Explanation: An axiom of health promotion and disease prevention is the fact that health education is highly beneficial. These benefits are not the same for everyone, but everyone can benefit from some sort of health promotion, including older clients. Strenuous exercise is not appropriate for everyone. Education does not always need to happen in a formal healthcare setting.

Prior to the discharge of a client who is recovering from a stroke from an acute care facility, the nursing case manager has the nursing staff, client, client's family, physical therapist, and home health nurse meet. The most likely purpose of this meeting is to: -provide client education. -determine hospital-based services needed by the client. -prepare the client for home care. -evaluate the effectiveness of the hospitalization.

prepare the client for home care. Explanation: Given that this client is being discharged from the acute care facility following a stroke, it is most likely that the nurse is calling a meeting of the entire health care team and the client and family to prepare the client for home care. Simply providing client education or evaluating the effectiveness of hospitalization could be done by the nurse alone and would not warrant calling a meeting with the entire health care team. As the client is being discharged, there is no reason to discuss hospital-based resources that the client might need.

When preparing to transfer an older adult client back to the long-term care facility where the client has been for several years, it is the primary responsibility of the nurse to: -provide for the coordination and continuity of care by the health care providers. -ensure that the current health state of the client is maintained. -discuss the return to familiar surroundings with the client. -communicate to the next of kin so they are aware of the transfer.

provide for the coordination and continuity of care by the health care providers. Explanation: The primary responsibility of the nurse is to ensure continuity of care by communicating the client's status and needs. The nurse cannot ensure the health status of the individual. The nurse may notify the next of kin of the transfer and also discuss this with the client, but these are not the primary nursing responsibilities.

Public health nursing is the branch of nursing that: -provides primary care to individuals. -administers care for a defined geographic community. -assesses individuals for community care. -provides health care for the community.

provides health care for the community. Explanation: Public health nursing focuses on the whole population and the health of the community at large, not just on assessing or providing care to individuals. Community-based nursing, not public health nursing, involves administering care for a defined geographic community.

When a client is admitted to the hospital, admissions personnel are required to determine whether the client has a document indicating advanced directives. If so, a copy is made for the client's medical record. The advanced directive document indicates: -that the client refuses to have resuscitation measures or any life-prolonging care. -that the client has made wishes for terminal care known. -that the client assigned a relative to act on the client's behalf. -that an attorney has verified the living will papers.

that the client has made wishes for terminal care known. Explanation: It is important to determine whether the client has advanced directives, which indicate the client's wishes regarding future care should the client become unable to communicate them. Advanced directives may be documented in a living will or a durable power of attorney for health care document. A copy should be placed in the client's hospital record. Simply having an advanced directive only means that the client has expressed some wishes regarding terminal care, not necessarily that an attorney has verified the document, that the client has refused to have resuscitation measures or any life-prolonging care, or that the client has assigned a relative to act on the client's behalf, although any or all of these could be true.

On admission to the hospital, each client is asked whether the client has a living will or a durable power of attorney. If not, the admitting staff person provides a sample form to the client if wanted. The purpose of this inquiry is to determine: -whether the client has a document describing wishes for care when the client is no longer able to make decisions. -what the client wants to have happen during the hospitalization. -how the client feels about being resuscitated and maintained on life support if this is necessary. -previous decisions made regarding whom to contact should the client die in the hospital.

whether the client has a document describing wishes for care when the client is no longer able to make decisions. Explanation: It is important to determine whether the client has advanced directives that describe the client's wishes for care if unable to communicate or participate in health care decisions. Although these advanced directives cover the client's desires regarding whether to be resuscitated or maintained on life support should it be necessary, the inquiry is regarding whether the client has a document (an advanced directive) stating these desires, not what the client's feelings about these issues are. A copy of any advanced directives should be placed in the client's hospital record. What the client wants to have happen during hospitalization and previous decisions made regarding whom to contact should the client die in the hospital are not relevant to whether the client has an advanced directive.