Chapter 41. Community & Home Nursing

A 56-year-old man is hospitalized because of poorly controlled diabetes and a leg ulcer that developed as a complication of diabetes. He is awake, alert, and oriented but fatigued and in need of wound care. In the hospital, he was placed on insulin and started on a variety of oral medications. He is learning how to check his blood sugar and administer insulin. He has never given himself insulin, and he does not understand how to interpret his blood sugar readings. The physician has prescribed discharge from the hospital with home health follow-up. Is this an appropriate referral? 1)Yes; the patient is in need of skilled services and, therefore, is eligible for home care services. 2)Yes; the patient has been unable to control his diabetes, is noncompliant, and needs to be monitored. 3)No; the patient should remain hospitalized; he has too many needs for home care services. 4)No; the patient is relatively young and oriented; he should be able to provide his own care.

ANS: 1 A client must require skilled services in order to be eligible for home care services. This patient needs wound care, to be taught about diabetes care, and to be monitored. These are all skilled services. All of these needs can be met with home care services. He is alert and oriented, which is important for planning teaching sessions. PTS:1DIFgrinifficultREF:p. 1511

The community health nurse has gathered data about the community. She identifies many weaknesses in the community health system that contribute to poor health outcomes. What should be her next step? 1)Prioritize the list of problems. 2)Validate the data. 3)Evaluate the effectiveness of the interventions. 4)Plan the care.

ANS: 1 After a thorough assessment, the nurse compiles a list of community strengths and weaknesses. Once this list is in place, the nurse must prioritize the list considering the client needs, funding, and political feasibility. PTS:1DIF:ModerateREF:p. 1507 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

A home health nurse has called his patient to arrange an initial home visit and has driven to the home. What is the nurse's objective in the first few minutes of the visit? 1)Develop rapport and trust with the patient and family. 2)Gather demographic data and complete the referral form. 3)Assess the patient's most important health needs. 4)Determine the patient's needs for ongoing care.

ANS: 1 All of these objectives are appropriate for the home health visit. However, the first few minutes of the initial visit set the tone for the relationship among client, nurse, family, and agency. In that time, the nurse focuses on developing rapport and trust. Once rapport and trust have been developed, the nurse can gather data, assess the client, and determine the need for ongoing care. PTS: 1 DIF: Moderate REF: p. 1516 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Synthesis

A community health nurse is evaluating the current health programs in the community. Which of these outcomes would indicate a healthy community? 1)Ninety percent of members report adequate access to primary care services. 2)Immunization services are available at hospitals and clinics. 3)Affordable housing in the community is under construction. 4)Mortality rates have been stable over the past 5 years.

ANS: 1 Evidence of health in a community can be judged by examining progress in the focus areas delineated in Healthy People 2020. Access to primary care services is a measurable outcome that provides evidence of effectiveness of health programs. The availability of immunization services at the hospital or at many offices does not provide evidence that these services are being utilized. Similarly, the fact that affordable housing is under construction does not mean that it is being accepted and used or that enough is being built. Mortality rates may be stable but could be quite high and within unacceptable parameters. PTS:1DIFgrinifficultREF:p. 1500

A nurse serving the community in a public health role would likely perform which of the following functions within a particular community? 1)Tracking the prevalence of gonorrhea between January and June 2)Screening for scoliosis among 12- to 14-year-old girls in middle school 3)Weighing premature infants receiving phototherapy at home 4)Giving the H1N1 vaccine to fire and police personnel

ANS: 1 Public health nursing focuses on the community at large and the eventual effect of the community's health status on the health of individuals, families, and groups. The goal of public health is to prevent individual disease and disability, in addition to promoting and protecting the health of the community as a whole, such as tracking the prevalence of disease. Activities, such as scoliosis screening, home care, and vaccination program, are examples of community health nursing. PTS:1DIF:ModerateREF:p. 1501

A family caregiver is learning to administer insulin injections to her homebound sister. What should the nurse advise her to do with the used needles? 1)Discard the needle and syringe in a thick plastic milk jug with a lid. 2)Securely recap them and place them a paper bag in the household trash. 3)Remove the needle and put it in a coffee can with a lid; put the syringe in the trash. 4)Do not recap the needle; break it by bending it on the tabletop.

ANS: 1 The caregiver should discard the syringe and needle in a thick plastic milk jug with a lid, a metal coffee can with a lid, or a commercial sharps container. Patients and caregivers should not recap used needles. They should not remove the needle from the syringe or attempt to break it because this increases the risk of needlestick injury. PTS:1DIF:ModerateREF:p. 1520

A 56-year-old woman provides care to her 91-year-old widowed father. She says she is frequently fatigued and that she no longer socializes with her friends. "I'm so busy taking care of my dad. It's really hard work because he is bedridden. Sometimes it breaks my heart when I have to feed and bathe him. He always seemed so strong when I was a child." The most appropriate nursing diagnosis for this woman is: 1)Caregiver Role Strain 2)Impaired Home Maintenance 3)interrupted Family Processes 4)Risk for Caregiver Role Strain

ANS: 1 This caregiver is experiencing fatigue, isolation, and difficulty adjusting to role changes. These are signs of Caregiver Role Strain. Because symptoms exist, this is an actual problem as opposed to a potential problem. There is no evidence of Impaired Home Maintenance. Although family processes have been altered, this is not the best nursing diagnosis based on the defining characteristics given. PTS: 1 DIF: Moderate REF: p. 1517

A community health nurse is assigned to work in a different area of the city. Which of the following assessment techniques would she likely use to develop an overview of the community? Choose all that apply. 1)Windshield survey 2)Review of demographic data 3)Physical assessment of a sample of the inhabitants 4)Review of the records of area providers

ANS: 1, 2 A windshield survey and review of demographic data provide data about the community. She may interview area residents about their experiences or ideas about this community; however, physical examination of a sample of the inhabitants would not give her community-level data. Similarly, she may wish to meet with area providers, but reviewing their records violates HIPAA laws and assumes that the records accurately reflect the health concerns of the population. PTS:1DIF:ModerateREF:p. 1506

Which of the following is a primary intervention? Choose all that apply. 1)Immunization for meningitis of college-bound students 2)Safer sex education for high school students 3)Lobbying for health education in the schools 4)Tuberculosis screening via PPD testing

ANS: 1, 2, 3 Primary interventions are interventions that occur before disease appears. The goal of primary interventions is to promote health and prevent disease. Secondary interventions aim to reduce the impact of the disease process by early detection and treatment. Tertiary interventions aim to halt disease progression and restore client functioning. PTS:1DIF:ModerateREF:p. 1503 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

The nurse is visiting a patient who lives alone in a two-room house. The patient requires wound care and medication management, but his health is not expected to improve much, even with care. There is no running water in the house, and the bathroom is in disrepair and filthy. At the first home visit, which of the following should the nurse assess? Choose all that apply. 1)Wound status 2)Patient concerns 3)Ability to perform care independently 4)End-of-life planning

ANS: 1, 2, 3 The nurse should assess the patient's status, condition of the wound, concerns, and ability to perform care independently. End-of-life care is a topic the nurse may wish to explore after a relationship has developed. PTS:1DIF:Easy

Identify the nurse who is acting as a community health nurse. Choose all that apply. 1)School nurse who provides screening and direct care in the elementary school 2)Parish nurse who offers health education after services each Sunday 3)Nurse who works for the Red Cross by providing disaster relief 4)A nurse administering vaccines to inmates in a correctional facility

ANS: 1, 2, 3, 4 Community health nurses function as client advocates, counselors, case managers, educators, and collaborators for patients and their families in the community setting. All of these nurses are working in community health settings in roles as school nurse, parish nurse, disaster nurse, and prison nurse. PTS: 1 DIF: Easy REF: pp. 1501-1503

Which of the following services are provided by home health agencies? Choose all that apply. 1)Direct care of clients in the home, performing treatments 2)Indirect care such as provision of medication and supplies 3)Acute care services for clients with complex diseases 4)Respite care of clients to relieve family caregivers

ANS: 1, 2, 4 Home care agencies provide direct, indirect, and respite care in the home. Acute care services are provided in the hospital. PTS:1DIF:ModerateREF:p. 1511

Which of the following groups represents a vulnerable population? Choose all that apply. 1)Homeless persons with no known illnesses 2)Women who have experienced domestic violence 3)Fifth-grade students at the local elementary school 4)Persons with type 1 diabetes mellitus

ANS: 1, 2, 4 Vulnerable populations include those with limited economic or social resources, the very young and the very old, those with chronic disease, and people who have experienced abuse or trauma. PTS:1DIF:ModerateREF:pp. 1500-1501 KEY: Nursing process: Assessment | Client need: Physiological Integrity | Cognitive level: Application

A community health nurse prepares for a new assignment. She has been assigned census tracts 131 and 132. This large area crosses the border of two towns and includes 4,000 people. As a community health nurse, she recognizes that assignments are based on census tracts because census tracts do which of the following? Choose all that apply. 1)Define the geopolitical boundaries of a community. 2)Are made up of persons who share a common heritage and customs. 3)Divide populations into smaller groups that can be assessed more readily. 4)Are natural divisions in communities that are based on voting patterns.

ANS: 1, 3 Census tracts are derived from the national census. They typically include 1,500 to 8,000 people. The area of the tract varies based on the density. Census tracts show geopolitical boundaries that are useful to anyone who studies the characteristics and concerns of smaller groups of people. PTS:1DIF:ModerateREF:p. 1499

Home healthcare and home hospice care are two different types of home health services. What are the differences between these services? Choose all that apply. 1)Home healthcare promotes independence in clients; home hospice care promotes comfort and quality of life. 2)Home healthcare promotes comfort and symptom management; hospice care promotes self-care. 3)Home healthcare is focused on teaching self-care; home hospice care is focused on teaching skilled care to caregivers. 4)Home hospice care is focused on managing symptoms; home healthcare is focused on fostering independence.

ANS: 1, 4 The purpose of home healthcare is to promote self-care and foster independence. The purpose of home hospice care is to promote comfort and quality of life by managing symptoms. PTS: 1 DIF: Moderate REF: p. 1512 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

The similarities between the Omaha System and the NANDA-I taxonomy are that both contain which of the following? 1)Evaluation tools expressed in standardized language 2)Nursing diagnoses expressed in standardized language 3)Diagnoses, outcomes, and interventions 4)Labels that are intended for use in any healthcare setting

ANS: 2 NANDA-I and the Omaha System both contain nursing diagnoses expressed in standardized language. The Omaha System also contains outcomes and interventions. The Omaha System was developed for use in community settings, whereas NANDA-I may be used in all settings. PTS:1DIF:ModerateREF:p. 1507 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis

A community health nurse planning a new program for teen pregnancy prevention designs a community assessment covering the structure of her target. Which of the following areas would she include? 1)Number of residential and commercial buildings 2)Demographic data of the residents 3)Morbidity and mortality rates of the population 4)Common strategies for conflict resolution

ANS: 2 Structure refers to the general characteristics of a community. These include demographic data, such as gender, age, ethnicity, and educational and income levels, as well as data about healthcare services, such as the number of primary care providers or emergency departments in the area. PTS:1DIF:ModerateREF:p. 1500 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application

A community health nurse prepares for a new assignment. She has been assigned census tracts 131 and 132. This large area crosses the border of two towns and includes 4,000 people. What components of the community must the community health nurse assess prior to beginning her new assignment? 1)Income levels, health status, and relationships among groups 2)Structure of the tracts, effectiveness of the community, and current status 3)Number of clients with health problems compared to the number of healthcare providers 4)Community organizations and beliefs about their role in the community

ANS: 2 To understand a community and its needs, the nurse must assess the community's structure, status (the biological, social, and emotional outcome components of the community), and process (overall effectiveness of the community). Income level and demographic data, such as community organizations and healthcare providers, are included in the assessment of the community structure. The number of clients with health problems is only a part of the assessment of the community status. PTS:1DIFgrinifficultREF:p. 1500

The nurse has been assigned to a caseload of home health clients. Before making home visits, which two planning activities must she perform first? 1)Order supplies for the home care services. 2)Review the cases to determine the reasons for the visits. 3)Contact the clients to arrange for the visits. 4)Develop a schedule for the day so that all visits can be made.

ANS: 2, 3 All of these interventions are appropriate. However, it is essential to determine the nature of the visits and to secure permission for visiting before the nurse can order supplies and plan her day. PTS: 1 DIF: Difficult REF: p. 1514

Which of the following clients would most likely require home health services? Choose all that apply. 1)45-year-old man with an injured rotator cuff that requires surgery 2)32-year-old terminally ill woman with a supportive family 3)92-year-old man living independently with multiple medical problems 4)6-year-old with a fractured hip requiring a leg and pelvic cast

ANS: 2, 3 Home care is appropriate for a client with health needs that exceed the abilities of family and friends. Older adults who wish to avoid placement in a skilled nursing facility, those who require ongoing skilled care after discharge from the hospital, the terminally ill, and persons with chronic illness that must be monitored to avoid hospitalization are the most likely home health clients. PTS:1DIF:Moderate REF: p. 1510; critical-thinking item requires synthesis of knowledge acquired from passage

Which of the following interventions has a public health focus? Choose all that apply. 1)Controlling the blood sugar of a diabetic client with cardiovascular disease 2)Assisting with the launch of an after-school program in a high-crime neighborhood 3)Providing an influenza vaccination program for seniors and persons with chronic illness 4)Offering counseling to the family of a child with severe cognitive deficits

ANS: 2, 3 Public health nursing focuses on the community at large and the eventual effect of the community's health status on the health of individuals and families. Diabetic care is focused on individual health. Family counseling is focused on family health. PTS:1DIF:Moderate REF:p. 1501; question involves critical thinking with synthesis of information acquired from reading this passage

The inhabitants of Yulupa, California, form which of the following? 1)Aggregate 2)Community 3)Population 4)Vulnerable population

ANS: 3 A population is all of the people inhabiting a specified area. In contrast, a community is a group of like-minded individuals or one whose members have a common purpose, and an aggregate has shared characteristics. A vulnerable population is an aggregate with increased risk for poor health outcomes. PTS: 1 DIF: Moderate REF: p. 1499

Which of the following unique aspects of home care do Medicare reimbursement regulations require that the nurse include in documentation? 1)Patient assessment data and interventions performed 2)Patient response to care and assessment of environment 3)Evidence of homebound status and continued need for skilled care 4)Skilled care delivered and communication with other providers

ANS: 3 All of the aspects mentioned should be documented. However, the unique requirements of home care include documentation of homebound status and the continued need for skilled care. PTS:1DIF:ModerateREF:p. 1513 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application

The community health nurse is working with the residents of government-subsidized senior housing. She meets with them regularly to discuss concerns and evaluate whether they receive healthcare that meets their needs. Which of the following nursing roles best describes these actions? 1)Case manager 2)Client advocate 3)Collaborator 4)Counselor 5)Educator

ANS: 3 As a collaborator, the nurse forges partnerships and coalitions that can effectively address common concerns among different communities. In this role, the nurse facilitates discussion to work toward problem resolution. As a case manager, the nurse makes referrals to or collaborates with other health and social agencies. In the client advocate role, the nurse supports the identified or voiced concerns of the client or community. As an educator, the nurse focuses on wellness and disease prevention through patient teaching. A counselor offers practical solutions to resolve problems. PTS:1DIF:ModerateREF:p. 1502

Documentation in home healthcare may take many forms. Some nurses use NANDA-I terminology for diagnoses, whereas others use the Clinical Care Classification (CCC) system. The chief benefit of the CCC system is that it: 1)Contains diagnoses specific to home care, whereas NANDA-I does not. 2)Is simpler to use and more readily understood by other disciplines. 3)Is linked to the OASIS reporting forms required by Medicare. 4)Uses standardized terminology, whereas NANDA-I does not.

ANS: 3 Home care nurses more commonly use the CCC because it is linked to the OASIS reporting forms required by Medicare. The CCC was developed for use in home care; however, the diagnoses themselves are not specific to home care. They can be used in any setting. NANDA-I, NIC, and NOC all use standardized language that may be used in any setting, including home healthcare. NIC and NOC have some interventions and outcomes that are specific to home care use. PTS:1DIF:ModerateREF:p. 1517

A patient was involved in a motor vehicle accident that resulted in multiple traumatic injuries. He was hospitalized for 8 days in the intensive care unit and 3 days on the surgical floor. He has been discharged home with home health support. Identify the primary goal of his home care: 1)Provide comprehensive direct care. 2)Promote sleep and rest for healing. 3)Teach the patient and family how to provide care. 4)Explain how home care differs from hospital care.

ANS: 3 The primary goal in home healthcare is to promote self-care. Nursing activities are directed at fostering independence or teaching the family or other caregivers to assist the client with ongoing needs. Care continues to be comprehensive; however, rather than providing direct care for all needs, the emphasis shifts toward fostering independence. PTS:1DIF:ModerateREF:p. 1510

A community health nurse gathers information about how individuals in a low-income neighborhood perceive the community and its state of health. Which of the following assessment strategies would be appropriate? 1)Conducting a windshield survey while driving 2)Reviewing a multitude of community databases 3)Interviewing residents living on every fifth block 4)Analyzing demographic data on the community

ANS: 3 To assess community perceptions, the nurse will need to interact with a cross-section of the community. Interviewing residents is one way to find out about community concerns and opinions. The other methods are assessment strategies that will provide data about the community but do not offer information on how community members view the community. PTS:1DIF:ModerateREF:pp. 1506-1507

The nurse is visiting a client who resides in a single-room occupancy hotel. Groups of people are leaning against the building and smoking on the steps. There is obvious drug abuse occurring in the lobby and halls of the building. There is no running water in the room, and the bathroom down the hall is in disrepair and filthy. A primary concern that the nurse must consider when making this visit is safety. Which of the following actions are appropriate safety measures? Choose all that apply. 1)Notify the police that the nurse plans to visit this site. 2)Carry something that can be used as a weapon if necessary. 3)Inform the home health agency of the nurse's route and time of visit. 4)Do not visit if the nurse senses danger when he arrives at the site.

ANS: 3, 4 Safety is a primary consideration in home care. The nurse should file a route and planned schedule with the agency. In addition, he should not enter the building if he feels he may be in danger. He should notify the police if he senses danger, but not to tell them of a planned visit. The nurse should always carry a cell phone to alert police when security is threatened. It is not recommended that the nurse carry a weapon. PTS:1DIF:ModerateREF:pp. 1514-1515

A home health nurse is working with a physical therapist and home health aides to work out a schedule for their visits that will best address the patient's needs. Which nursing role does this demonstrate? 1)Direct care provider 2)Client and family educator 3)Client advocate 4)Care coordinator

ANS: 4 A care coordinator manages and coordinates the services of members of the healthcare team and develops a plan of care that addresses the client's needs. Direct care involves hands-on tasks, such as dressing wounds and administering medications. The educator role involves communicating with clients and families to help them develop the skills involved to administer self-care. A client advocate supports the client's right to make decisions and protects the client from harm if he is unable to make decisions. PTS:1DIF:EasyREF:p. 1512 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

At a home visit, the nurse asks the patient, "Have you taken your blood pressure medicine today?" The patient replies, "I don't remember. Maybe." On the table are several bottles of medication, some open, some not. They have all been prescribed for the patient. The patient cannot say how often to take each one, when asked. A compartmentalized medication organizer is on the table, with a few capsules in it, and some compartments left open. What should the nurse do? 1)Show the patient how to put the medications in the organizer for the next 2 days, and observe while he fills the rest of the organizer. 2)Arrange for a home health aide to come each day to show the patient which pills to take. 3)Administer today's medications and arrange for the pharmacy to put medications in easy-to-open containers in the future. 4)Fill the organizer for each day of the week, explain how to use it, and return in a day or two to evaluate

ANS: 4 From the cues given, it seems likely the patient would not be able to accurately load the medication organizer—and, in fact, may not be able to use it properly to take the correct medications at the correct time. The nurse would need to return every day or so until he is certain that the patient can actually administer his own meds after someone else loads the organizer. Showing the patient how to load the organizer solves part of the problem; however, this would not allow the nurse to evaluate whether the patient would then know to take the medications each day. Home health aides cannot be responsible for patient medications. There is no indication that the patient is having difficulty opening his medication containers, so there is no need to talk to the pharmacy. PTS:1DIFgrinifficult

What is the type of nursing with a focus on the community as a whole and the health status of individuals as an aggregate? 1)School nursing 2)Community health nursing 3)Community-oriented nursing 4)Public health nursing

ANS: 4 Public health nursing focuses on the community at large and the eventual effect of the community's health status on the health of individuals, families, and groups. Community health nursing focuses on the health of individuals, families, and groups and on how their health affects the health of the community. Community-oriented care combines elements of community health nursing and public health. School nursing focuses on optimizing health for a community of students in a school setting. PTS: 1 DIF: Moderate REF: p. 1501

Today is the last day of work on the medical-surgical unit for a nurse who has decided to work in home care. A patient asks her why she is going to home care. Select a response that best illustrates the advantages of home care. 1)"Care is much more comprehensive and unhurried in the home; it is more enjoyable for nurses to work in home care." 2)"Home care is much more organized than hospital care; you have access to the whole team, and there is less interference from others." 3)"A home health nurse has more autonomy and skills than a hospital nurse; I'll get to do more." 4)"In home care I can see my patients in their personal environment; this will help me understand them more and allow me to give personalized care.

ANS: 4 The home is the client's personal environment: a window into the patient's life. The nurse is able to see how the patient lives, interacts, and negotiates the world. Care, in the home and hospital, is comprehensive. In both locations, the nurse has obligations to other patients and will need to watch her schedule. The level of enjoyment a nurse has with her job is dependent on many factors. A disadvantage to home care is the lack of immediate assistance from other members of the health team. Home care nurses may be more autonomous than hospital nurses; however, their scope of practice is identical. PTS:1DIF:ModerateREF:p. 1511

The nurse is visiting a patient who lives in a single-room occupancy hotel. The patient requires wound care and medication management. There is no running water in the room, and the bathroom down the hall is in disrepair and filthy. The patient's room is not clean. What supplies would be essential for the nurse to bring with him when visiting this client? 1)All wound care supplies needed for the duration of the care 2)Reclosable plastic bags for disposal of old dressings 3)Small, biohazard sharps container to be left in the room 4)Waterless, antibacterial hand sanitizer solution

ANS: 4 The nurse should use a waterless antibacterial hand sanitizer in place of soap and water because there is no sink and conditions are filthy. The nurse should limit the supplies brought into the home if the conditions are not clean. Wound care supplies, for example, would be ordered and kept in the home. Old dressings should be double-bagged to prevent leakage, and discarded in the home. There is no evidence that a sharps disposal container is needed. PTS: 1 DIF: Moderate REF: p. 1520