Chapter 12: Collaborative Practice and Care Coordination across Settings

Which of the following members of the care team is most often responsible for providing the order that will begin a patient's course of home healthcare?

The physician

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

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

A client has had a total knee replacement and will need to walk with crutches for six weeks. The client is being discharged home with a referral for home health care. What will the home care nurse need to assess during her initial assessment?

Home environment

Home care nurses are required to complete the Outcome and Assessment Information Set (OASIS) according to:

Medicare.

The home health care nurse is providing information to a client and family on medication changes. What role is the nurse performing?

Client and family educator

The nurse is assigned to care for a client who will be transferred to the rehabilitation unit in the hospital following his postoperative recovery from hip surgery. 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.

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

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

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.

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 her." Which nursing response is indicated?

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

A nurse who provides care on a postsurgical unit is performing discharge education as a component of her effort to ensure continuity of care. Which of the following is the primary goal of continuity of care?

ensuring a smooth and safe transition between different health care settings

After teaching a class of nursing students about home health care, the nursing instructor determines that the education was successful when the class identifies what as a goal of home health care?

functioning within limitations

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 nursing assistant has settled the client in the room, and oriented the client to surroundings, call system, bathroom, bedside supplies, and where to place clothes. The priority is to:

gather information and complete admission database.

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.

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

Prior to the client's discharge 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 purpose of this is to:

prepare the client for home care.

When preparing to transfer an older adult client back to the long-term care facility where he 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.

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

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.

The nurse is performing a comprehensive assessment for a newly admitted home health client recently discharged from the hospital. Which type of data is important to the home health nurse?

subjective data about how the client manages medications at home

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

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

using therapeutic communication.

A client newly diagnosed with cancer has been assigned a nurse navigator. The nurse offers additional explanation about this nurse's role when the client makes which statements? Select all that apply.

"I do have my husband to take me to my treatments." "I would rather have someone from the team caring for me."

A group of nursing students is discussing reasons why they would like to become home health nurses after licensure. The nursing instructor facilitating this discussion would offer additional information when which statement is made? Select all that apply.

"I don't think fast enough to work in a hospital." "I would like to spend more time talking with clients than doing skills."

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 purchase, offering rationale for our choices." "Before our next meeting, each of us will ask the nurses on our 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 discussing home health care during a presentation for a group of senior nursing students, as part of a Career Day seminar. One of the students asks, "How is home health care different from care in a hospital?" Which response by the nurse would be most appropriate?

"The client and family are in control of the setting, not the nurse."

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

Assessment

Many significant changes have been made to the health care delivery system in recent years. Earlier hospital discharges is one of them. What is one result of earlier hospital discharges?

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

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

Coordinating Making referrals Monitoring medical progress Filing and completing paperwork

A successful discharge includes effective planning. Identifying and meeting client needs beyond the acute care facility reduces readmissions. Which nursing role is of great importance to this success?

Coordinator

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

The nurse is admitting a client for outpatient surgery. When asked what the client had been told about self-care following discharge the client says, "No one has told me anything." Which nursing intervention is indicated?

Provide the teaching.

In anticipation of discharge, a nurse is teaching the daughter of an elderly client how to change the dressing on her mother's venous ulcer. Which teaching strategy is most likely to be effective?

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

The home health nurse is conducting a home safety assessment during the admission of a homebound client. What should the nurse be sure to include when performing the assessment? Select all that apply.

Determine whether modifications can be done in the home. Determine whether the home is safe against home invasions Determine if the client has indoor plumbing Determine if there are pest infestations.

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

Educator

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

Gather supplies for the visit. Establish rapport with client and family. Assess the client and home situation. Educate the client and family about promoting self-care.

The nurse is assigned to care for a middle-aged client who is very agitated and wants to go home. The client states that he 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.

A woman living alone has degenerative joint disease, hypertension, and neuropathy. It is difficult for her to bathe herself, and her blood pressure is unstable. What type of care would this client benefit from most?

Home care

A nurse desires to work in a community-based setting. Which setting would the nurse seek employment? Select all that apply.

Homes Schools Workplaces

Which of the following is the largest single source of reimbursement for home health care services?

Medicare

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

Occupational therapist

Which type of home healthcare agency is a local health department?

Official or public agency

The nurse is assigned to care for an older adult client who suffered a stroke. The client will soon be going home. When the nurse is actually doing the discharge planning, what is the nursing priority?

Plan reachable goals with the client and family.

The nurse is assigned to care for a client who will be transferred to the rehabilitation unit in the hospital following his postoperative recovery from hip surgery. 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.

A client visits the health care facility, where the nurse provides primary health care. Which service would the nurse most likely provide?

Screening

A nurse is talking with a community-based nurse at a local job fair and asking this nurse about what's it is like to practice in the community. The community-based nurse tells the other nurse, "You need certain qualities to work in this area." Which quality would the community-based nurse identify? Select all that apply.

Strong knowledge foundation Effective communication skills Keen physical assessment skills

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 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.

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.

A client is having an increasing amount of difficulty caring for herself in her home alone. She states to the nurse, "I need more help. What am I going to do?" What would be important for the nurse to do?

The nurse should have the social worker visit to discuss care options.

Continuity of care for a particular client is important to prevent:

fragmentation of services.

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 his visits. Which aspect of the admission process does this represent?

clearly defining the purpose and expectations of the admission

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

communicate her feelings to family and friends.

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 nurse is preparing to discharge a client from an acute care facility. Which action must be performed by the nurse upon discharge of this client?

coordinating future care for the client

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 nursing assistant has settled the client in the room, and oriented the client to surroundings, call system, bathroom, bedside supplies, and where to place clothes. The priority is to:

gather information and complete admission database.

Community-based health care is best defined as:

health care developed in partnership with communities.

A single parent age 17 years, with one child and pregnant with her second child, has the mental age of a 12-year-old. What is the home care nurse's greatest concern in caring for this woman?

her cognitive ability to understand

On admission to the hospital, clients are asked if they have a living will or a durable power of attorney. If not, the admitting staff person will provide a sample form to the client if they want it. The purpose of this inquiry is to determine:

if the client has a document describing wishes for care when he/she is no longer able to make decisions.

Prior to the client's discharge 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 purpose of this is to:

prepare the client for home care.

Public health nursing is the branch of nursing that:

provides health care for the community.

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

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.

An 82-year-old woman is being discharged from the hospital following a bowel resection. The woman lives alone and her family is out of town. Which factor will have the greatest effect on her home care management?

support systems

Nurses now have the option to practice in a variety of settings. One of the fastest growing venues of practice for the nurse in today's health care climate 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