Chapter 12 - Collaborative Practice and Care Coordination Across Settings

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.

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?

Clearly defining the purpose and expectations of the admission

One significant change in the health care delivery system in recent years is earlier hospital discharges. What is one result of earlier hospital discharges?

Clients with high home care needs are being discharged into the community.

IIn 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?

Demonstrate and explain the procedure and then have the daughter perform it.

Which activity by the nurse exhibits the role of family educator?

Demonstrating how to suction the oropharynx.

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?

Documented need for a speech pathologist

Which measure should a home health care nurse integrate into routine practice to minimize the potential for lawsuits?

Perform thorough, accurate, and timely documentation.

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 client's identified needs and goals

A nurse coordinator for a busy hospital provides for continuity of care for clients using the hospital services. Which cognitive skill would this nurse need to ensure continuity of care?

The knowledge of how to communicate client priorities and the related plan of care as a client is transferred between different settings

It is important for home health care nurses to remember which point?

The nurse is the guest in the client's home.

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 prepares the new room for the client.

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 physician

pallative care

care for seriously ill persons focused on providing relief from symptoms

The initial step in discharge planning is:

collecting and organizing data about the client.

A 16-year-old client has been injured in an accident and is receiving home care due to fractures and multiple trauma-related injuries. The client states, "I don't know why I survived and not my best friend." It is most important for the home care nurse to encourage the client to:

communicate these feelings to family and friends.

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.

transfers out of facility to another

send copy only to new facility

A nurse is caring for a 17-year-old pregnant teenager who needs to obtain assistance with essential baby items such as a crib. The client mentions not having any income from a job. The nurse should encourage the client to go to a:

social welfare office.

When the nurse begins the entry phase of the home visit, the most important nursing action is:

using therapeutic communication.

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.

"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."

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."

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 is scheduled for a cardiac catheterization in about an hour and needs monitoring every 15 minutes."

The home care nurse asks the client and family about their socioeconomic status, culture, and beliefs. This occurs during which phase of care?

Assessment

Which action must the nurse perform on discharge of a client from an acute care facility?

Coordinating future care for the client

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?

Coordinator

A nurse is caring for a client who will be discharged home but will have a complex medication regimen and follow-up with several providers. Which strategies will the nurse employ to provide discharge teaching? Select all that apply.

Divide the content into several short sessions. Be prepared to review and repeat information. After teaching have the client repeat back the key points. Use visual aids to help explain teaching.

Which role is the home health nurse exhibiting when demonstrating how to suction the oropharynx of the client?

Educator

An 18-month-old child is ventilator-dependent due to infantile scoliosis. This is the first time the child has been home since birth and the parents are very concerned about providing care. What is this family's priority need for assistance?

Emotional bonding

Which is the primary goal of continuity of care?

Ensuring a smooth and safe transition between different health care settings

When initiating home health care services, during which phase is it appropriate for the nurse to implement the initial client assessment?

Entry phase

A nurse is preparing a room for client admission. Which actions follow recommended guidelines for this process? Select all that apply.

Fold back the top bed linens. Assemble the necessary equipment and supplies, including a hospital admission pack. Adjust the physical environment of the room, including lighting and temperature.

Which is the primary goal of home health care?

Functioning within limitations

Which activities should the nurse engage in during the pre-entry phase of the home visit? Select all that apply.

Gather supplies for the visit. Review the client's treatment orders. Evaluate the safety of the neighborhood

The nurse is assigned to care for a middle-aged client who is agitated and wants to go home. The client states that the client does not have time to waste in the hospital, and no one is doing anything anyway. Which action by the nurse is most appropriate if the client insists on leaving the hospital against medical advice (AMA)?

Have the client sign the AMA form.

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

A nurse working in a primary health care facility would most likely provide which service?

Screening

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 discharge home of clients who are more critically ill

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 registered nurse

When meeting a new client on arrival to the unit, what is the nurse responsible for during the admission process? Select all that apply.

Welcoming the client as if to the client's home Assessing the family's need to be present during the admission Asking the client whether the client wants the family to remain during the admission process Communicating the rules about visiting hours, the cafeteria, and other services

advanced directive (living will)

details the conditions under which life support measures should be used

community-based nursing

geographical on individuals and families

Community-based health care is best defined as:

health care developed in partnership with communities.

community-health nursing

overall health of the community

home visits

pre-entry stage entry stage

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.

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:

coordinate uninterrupted care and facilitate transfer between units and levels of care.

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?

Nurse-client rapport

The client is being discharged to the home setting following a stroke. The client requires assistance in relearning how to cook safely. To which home health care team member should the nurse refer the client?

Occupational therapist

The nurse is assessing the client's readiness to be discharged home after being admitted for 4 days due to falling at home. Which question should the nurse ask the client?

"What medications will you be taking at home?"

A client's son says, "Mom can come and live with me, but I will need help. I am going to call a home health agency to see about having someone come out to my house." Which nursing response is indicated?

"Your mother's primary health care provider will have to write a prescription for home health."

entry stage

- establishing rapport - assessments - check environment for safety

pre-entry stage

- make contact - supplies - view their history - safety of neighborhood

continuity of care

Continuation of care smoothly from one provider to another, so that the patient receives the most benefit and no interruption in care. SBAR

Which are components of the nursing case management process? Select all that apply.

Coordinating Making referrals Monitoring medical progress Filing and completing paperwork

Which are examples of subjective client information? Select all that apply.

Marital status and occupation Smoking and alcohol history List of medications

Home health care nurses are required to complete the Outcome and Assessment Information Set (OASIS) by which entity?

Medicare

The nurse is assigned to care for an older adult client who had a stroke and will be discharged soon from the acute care facility. Which actions by the nurse will help meet the client's outcomes for discharge? Select all that apply.

Assesses the needs of the client and family throughout the hospitalization Collaborates with the health care team to obtain referrals the client will need Teaches the client and family about medications and treatments Supports the caregivers as they adjust to the discharge

During the initial visit to a client's home, the nurse should provide the client and family with what information?

Available community resources to meet their needs

A single parent age 17 years, with one child and pregnant with a second, has the mental age of a 12-year-old. The home care nurse's greatest concern in caring for this client should be the client's ability to do which?

Cognitively understand how to care for the children

A nurse is assisting with the transfer of a client from the acute care facility to the rehabiliation facility for continued care. Which skill would be most important for the nurse to use to promote continuity of care?

Communication

The nurse 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

A pregnant client is on bed rest at home, and a nurse will soon come to the home to assess the client. Which type of nursing is this nurse practicing?

Community-based nursing

Which interventions would be performed by the occupational therapist as a member of the home health care team? Select all that apply.

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.

A client is having an increasing amount of difficulty caring for oneself in the home alone. The client states to the nurse, "I need more help. What am I going to do?" Which action would be the most appropriate for the nurse to take?

Have the social worker visit the client to discuss care options.

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?

High-rise toilet seat

A client living alone has degenerative joint disease, hypertension, and neuropathy. It is difficult for the client to bathe, and the client's blood pressure is unstable. Which type of care would this client benefit from most?

Home care

Which are community-based settings? Select all that apply.

Homes Schools Workplaces

What is the priority nursing responsibility when transferring a client from one unit in the hospital to another?

Provide a verbal report of the client's status to the admitting nurse.

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?

Demonstrate and explain the procedure and then have the daughter perform it.

When doing discharge planning for an older adult client who had a stroke, what is the nursing priority?

Plan reachable goals with the client and family.

The nurse is providing care to a homeless client who presents to the emergency department with a foot wound. Which is the priority nursing intervention prior to discharge?

Refer the client to social services for assistance.

The client is being discharged to the home setting following a stroke. Which activity would the occupational therapist assist the client with?

Relearning how to cook safely

A client is admitted to the acute care facility for the treatment of pneumonia. What exemplifies the nurse-managed care approach?

The case manager identifies dates when oxygen should be discontinued, bronchodilators changed to self-administered inhalers, and antibiotics changed from intravenous to oral treatment.

Which are examples of objective assessment information? Select all that apply.

Vital signs, height, and weight Findings on palpation of the abdomen

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?

Providing client education

A nurse is transferring a client from a hospital setting to a long-term care facility. Which action is most important to ensure continuity of care for this client?

Providing accurate and complete communication to the new facility

Which type of data is most important to a home health nurse who is performing a comprehensive assessment for a new client recently discharged from the hospital?

Subjective data about how the client manages medications at home

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?

Support system

Why is it important for the home health nurse to inform the health care agency of the nurse's daily itinerary?

Supports suggested safety precautions for the nurse when making a home care visit

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 change to shorter hospital stays

A nurse manager at a home health care agency is reviewing the medical record of a client who is receiving Medicare-based home health services. To ensure reimbursement for services, the nurse manager should consider whether which criteria have been met? Select all that apply.

The client is under the care of a physician. The client's condition is expected to improve in a reasonable time period. The client requires intermittent skilled services.

Which are recommended guidelines to prevent the spread of infection in the home care setting? Select all that apply.

Wearing gloves when contacting body fluids Using standard precautions Placing the bag on a liner before setting it down in the client's home

care coordination

coordination of services provided to patients before they enter a health care setting, during the time they are in the setting, and after they leave the 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:

prepare the client for home care.

Public health nursing is the branch of nursing that:

provides health care for the community.

The focus of community-based care is:

providing care to clients within a defined geographic area.

The nurse understands that planning for discharge actually begins at admission to the facility. The purpose of discharge planning is best described as:

providing continuity of care that is goal directed.

A home health care nurse develops a client's individualized plan of care during the:

entry phase.

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 has made wishes for terminal care known.

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's caregiver is absent whenever the nurse visits and the client is alone.

Which nursing action is appropriate when assuming the role of client case manager for a home health agency?

Managing client care from admission through discharge or resolution of illness

The nurse is caring for a client who would benefit from home health care services. In preparing for discharge, the nurse is aware that home health care can only be initiated if the:

physician writes an order for home care.

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