PrepU ch. 9: Care Coordination and Continuity in Health Care Settings and the Community

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

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 home care nurse is providing care and education to a woman who is pregnant with her first child. 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

Which type of agencies provide documented home health care services? Select all that apply.

Private businesses Private not-for-profit agencies Hospital-based agencies

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 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

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 caring for a patient who is in acute respiratory distress from pneumonia but refuses to stay for treatment. It is the nurse's responsibility to:

Notify the physician; discuss the outcomes of the patient's decision, and have the patient sign a release form.

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

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."

Which is not a cognitive or sensory deficit?

Asthma

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

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

Educator

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

Medicare

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

Medicare.

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

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 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

Which attributes of the PACE program are true? Select the correct answer.

It is a community program that helps patients to maintain their independence and stay in their home.

A student nurse is studying for an exam on community-based care and understands that the focus of community-based care is what?

Providing care to clients within a defined geographic area

Which facility is an example of a tertiary health care setting?

Rehabilitation facility

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

Why is it important for the 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 working in a hospital setting is responsible for transferring clients. Which recommended nursing actions would the nurse perform during this process? Select all that apply.

The nurse asks the family of a client moved to a critical care unit to take home the client's personal belongings. The nurse carefully packs the belongings of a client being discharged and sends them to the new facility. The hospital nurse prepares a detailed assessment and care plan to send to the long-term facility to which a client is transferred.

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 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

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

The exchange of information among the patient, the caregivers, and those responsible for care while the patient is in a care setting and after the patient returns home is key to a successful:

discharge planning.

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

fragmentation of services.

On admission to the hospital, patients 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 patient if they want it. The purpose of this inquiry is to determine:

if they have a document describing their wishes for care when they are no longer able to make their own decisions.

An example of a secondary level of health care is a(an):

inpatient cardiovascular surgery unit.

Which is a safety deficit?

multiple area rugs in the house of a 95-year-old

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.

Public health nursing is the branch of nursing that:

provides health care for the community.

When a patient is admitted to the hospital, admissions personnel are required to determine if the patient has a document indicating advanced directives. If so, a copy is made for the patient's medical record. The advanced directive document indicates:

that the patient has made his wishes for terminal care known.

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

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.