Chapter 12: Collaborative Practice and Care Coordination across Settings - ML8

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 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."

A nurse is using 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."

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

- Coordinating - Making referrals - Monitoring medical progress - Filing and completing paperwork

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 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 client and family about promoting self-care in ADLs. - Provide assistance with securing needed equipment.

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

The admission of the client includes a health history and complete assessment. The admission data is entered into the client's health record. Subjective assessment information includes:

- marital status and occupation. - smoking and alcohol history. - list of medications.

Which circumstance likely requires the most documentation and communication on the part of the nurse?

A geriatric client is being transferred from a subacute medical unit to a new long-term care facility following his recovery from pneumonia.

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.

A nurse coordinator for a busy hospital provides for continuity of care for clients using the hospital services. What 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

A nurse is completing a home visit to an older adult client who is receiving regular dressing changes for the treatment of her venous ulcer. What outcome does the nurse hope to achieve in the plan of care for this client?

to maximize the independence and health of clients.

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.

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 the nation and the world. What type of nursing is being practiced by this nurse?

Community health nursing

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 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

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

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 strategies 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.

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.

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

Educator

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

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

Entry phase

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.

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

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

Medicare

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

Which of the following measures should a home health care nurse implement into his or her practice to minimize the potential for lawsuits?

Perform thorough, accurate, and timely documentation.

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

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.

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

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

Relearn how to cook safely

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 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

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.

The nurse is met in the staff lounge by the nurse who has been caring for the client team on this shift. The off-going nurse says, "Sorry, but I have to get out of here." The nurse then gives a quick overview of each client on the team and says, "All the rest is in the chart if you need anything." Which essential part of the handoff is missing?

The opportunity for the oncoming nurse to ask questions.

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

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 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

The nurse recognizes that discharge planning begins upon admission and the initial step in discharge planning is:

collecting and organizing data about the client.

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

entry phase

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

fragmentation of services

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 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.

The nurse is caring for a client who will 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.

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.

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.

A nurse is caring for a 17-year-old pregnant woman that is unable to afford health care. What resource should the nurse suggest to the client to obtain support?

social service to inquire about Medicaid benefits

When a client is admitted to the hospital, admissions personnel are required to determine if 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 his wishes for terminal care known.

Despite the presence of various types of public and private home health care agencies, one similarity among all home health care agencies is:

the agencies must meet uniform standards for licensing, certification, and accreditation by state agencies and/or federal programs.