Chapter 12: Interprofessional Collaborative Practice and Care Coordination Across Settings

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 admitted to the hospital is diagnosed with cancer. The client is assigned a nurse who will be the central point of contact for all of the client's care. Which role is the nurse filling?

Nurse navigator

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

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

Public health nursing is the branch of nursing that:

provides health care for the community.

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.

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 home care nurse asks the client and family about their socioeconomic status, culture, and beliefs. Which is the best response by the nurse when the family asks why those questions are being asked?

"I want to ensure your care meets your unique needs."

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 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."

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?"

An 82-year-old client is being discharged from the hospital following a bowel resection. The client lives alone and the client's family lives in another city. When assessing for the factor that will have the greatest effect on the client's home care management, the nurse will ask what question?

"Who are the people in your life that you can rely on for support?"

The nurse is discharging five clients following surgeries. Which clients should the nurse consider candidates for referral to a long-term care facility? Select all that apply.

- A client who will need frequent physical therapy to regain strength. - A client who lives alone with few close friends or family. - A client whose spouse is debilitated and requires care.

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

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

Which qualities are essential for a community-based nurse? Select all that apply.

- Strong knowledge foundation - Effective communication skills - Keen physical assessment skills

A nurse is admitting a client to a hospital. Which actions should the nurse perform initially upon this admission? Select all that apply.

- The nurse asks the client to sign consent forms allowing treatment and the hospital to contact insurance companies as needed. - The nurse obtains client information, which is printed on an admission sheet and becomes part of the client's permanent record. - The nurse asks the client about existing advance directives; if none, the nurse gives the appropriate form to the client. - The nurse clearly describes how the client information will be used and disclosed to other parties. - The nurse gives the client a form explaining the Patient Care Partnership.

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

Which are examples of factors the nurse would assess to determine a client's functional abilities? Select all that apply.

- Whether the client wears eyeglasses - The client's ability to ambulate - The client's comprehension

A client says, "You guys are not doing anything for me. I am leaving." Which interventions are indicated by the nurse? Select all that apply.

- Witness the client's signature on the against medical advice form. - Inform the client of the risks of leaving.

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

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

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

Communication

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 17-year-old pregnant client who is unable to afford health care. Which action will the nurse perform to obtain assistance for this client?

Create a referral to the social work department.

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.

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

Educator

Which is the primary goal of continuity of care?

Ensuring a smooth and safe transition between different health care settings

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 unlicensed assistive personnel has settled the client in the room and oriented the client to the surroundings, call system, bathroom, bedside supplies, and where to place clothes. Which is the nurse's priority action?

Gather information and complete the admission database.

The nurse is providing education and interventions on health promotion and prevention of disease in the community. When planning this care, the nurse will integrate what guiding principle?

Health education can benefit both individuals and groups.

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 who is overseeing home health care ensures that Outcome and Assessment Information Set (OASIS) data are collected according to guidelines. The nurse's actions fulfill requirements of what entity?

Medicare

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

Official or public agency

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.

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 nurse will identify what purpose for this meeting?

Prepare the client to receive home care.

A client with severe congestive heart failure (CHF) has been referred to a long-term care facility. The nurse is transferring care from the hospital setting to a long-term care facility. Which action is a priority to ensure continuity of care for this client?

Providing accurate and complete communication to the new facility.

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 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.

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

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 health care provider

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.

For which client will the nurse provide a "simple referral" level of discharge planning?

client who will continue cardiac rehabilitation following discharge after a coronary artery bypass graft

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?

client's identified needs and goals

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 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 do not know why I survived and not my best friend." The nurse should prioritize what action?

encouraging the client to communicate these feelings to family and friends

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

entry phase.

Community-based health care is best defined as:

health care developed in partnership with communities.

A client living alone has degenerative joint disease, hypertension, and peripheral neuropathy. The client has challenges with activities of daily living, including hygiene. Which type of care would this client benefit from most?

home care

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

notify the health care provider, discuss the outcomes of the client's decision, and have the client sign a release form.