Fundamentals Nursing Chapter 9 Care Coordination and Continuity in Health Care Settings and the Community

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

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

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 home care nurse has just completed a dressing change on her client. Which statement best describes the termination phase?

"Your wound is healing nicely. It is draining less and it is smaller by a half centimeter."

A 47-year-old male has decided he requires more exercise, needs to eat a heart healthy diet, and avoid alcohol. This patient has determined which of the following?

A change in lifestyle influences health

Which is not a cognitive or sensory deficit?

Asthma

A nurse sits down with a client and explains the "Patient Care Partnership." This action best exemplifies what role of the community-based nurse?

Client advocate

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 activity by the nurse exhibits the role of family educator?

Demonstrating how to suction the oropharynx.

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 confirms that the bedside commode and walker has been delivered to the client's home. Which discharge planning event defines this intervention?

Facilitation

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

Fragmentation of services

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

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 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

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

Medicare

A school nurse at the local public high school has begun a program with his students that addresses safe sex and nonsmoking. This school nurse is classified as a(an)

Moral force for the public

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.

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 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.

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

Rehabilitation facility

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

Relearning how to cook safely

A home care nurse has completed a home assessment. Of the following findings, which should be reported to service providers immediately?

Smell of natural gas

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

A client is admitted to the acute care facility for the treatment of pneumonia. What exemplifies the nurse-managed care approach?

The case manager identifies dates when oxygen should be discontinued, bronchodilators changed to self-administered inhalers, and antibiotics changed from intravenous to oral treatment.

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

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.

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 caring for a client who decides to leave the hospital against medical advice (AMA). The nurse knows that the client must sign a form before leaving. What is the purpose of the AMA form?

To release the doctors and the institution from any legal responsibility

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

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.

A pregnant client is on bed rest in her home and a nurse will soon come to the home to assess the client. What type of nursing is being practiced in this setting?

community-base nursing

Occupational health nursing is classified as:

community-based health care

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.

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

entry phase

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

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, 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.

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

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 preparing referrals for an older adult client that will be discharged from a rehabilitation facility. Which community support services should the nurse suggest to assist in continuity of care? Select all that apply.

• Emergency answering services • Transportation • Meals on Wheels

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

The nurse is providing discharge planning for a client being discharged in the morning. For which situation should discharge planning be initiated by the nurse?

preoperative education for a client scheduled for cataract extraction

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.

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

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.

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 client is diagnosed with mild dementia while in the hospital. In preparing for discharge, what should the nurse discuss with the family?

the possible need for home care

What is the purpose of the Standards of Care and Standards of Professional Performance?

to guide the home care nurse in a collaborative role

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.

A nurse is discharging a client from the hospital. Which nursing actions should occur when a client is discharged from a health care setting? Select all that apply.

• Discharge planning should begin upon admission to the facility to ensure continuity of care. • The nurse ensures that the family members are taught the knowledge and skills needed to care for the client. • Preferably, the nurse who conducts the initial nursing assessment will determine the special needs of the client being discharged.

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 patient's vital signs, mental and code status, medications, and lab results • The nurse explains the patient's chief complaint, diagnosis, treatment plan, and patient wants and needs. • The nurse reports the current provider's assessment of the patient and need for further services.

The admission of the client includes a health history and complete assessment. The admission data is entered into the client's health record. What does objective assessment information include? (Select all that apply.)

• vital signs, height, and weight • abdomen soft to palpation