Chapter 11: The Healthcare Delivery System

Which six trends in health care reflect the Institute of Medicine's (IOM) focus?

"The system should be safe, effective, efficient, patient centered, timely, and equitable." A safe, effective, efficient, patient-centered, timely, and equitable system is what the IOM envisions. A bureaucratic, government-driven, illness-focused system is not advocated by the IOM.

A client asks a nurse about the benefit of using diagnosis-related groups (DRGs) as a reimbursement method. Which is the nurse's best response?

"DRGs have helped to reduce healthcare costs by decreasing the overall length of a client's hospital stay." The DRG system has been largely responsible for marked decreases in hospital lengths of stay. If hospital costs exceed the DRG payment for a client's treatment, the hospital incurs a loss, but if costs are less than the DRG amount, the hospital makes a profit. Decreasing hospital admission rates has not been shown to reduce the costs of health care. Health maintenance organizations (HMOs) focus on preventing illness through screening and health promotion.

A nurse says, "We have so many drills and safety checks for everything. It is almost like we are preoccupied with the possibility of failure." How should the charge nurse respond to this statement?

"Highly reliable organizations think about the possibility of failure and what to do to avoid it." Characteristics of high reliability organizations include preoccupation with failure, reluctance to simplify, sensitivity to operations, deference to expertise, and commitment to resilience.

At the last hospital unit meeting, the policy for the insertion of Foley catheters was revised based on current evidence. The new nurse on the unit just learned "the old way" and is frustrated to now have to learn a new methodology. Several other nurses comment that the change is "all about money." The charge nurse must educate the staff about the importance of this new policy. Which explanation by the charge nurse is most appropriate?

"Incorporating evidenced-based practice into our care routines links our interventions to valued outcomes, thereby increasing quality care. When we provide quality care, we can decrease cost." Evidenced-based practice improves client outcomes, thereby increasing the quality of care; quality care leads to decreased cost. Cost is a driver in quality health care delivery. Evidenced-based practice is not just a trend in care; it is an expectation in health care delivery. Clients are consumers of care, but they often do not understand evidenced-based care or the cost associated with care. Today's greater focus on quality makes it less likely that clients will suffer unnecessary or harmful treatment, reduces waste, and increases safety.

Which statement regarding health care reform trends is most accurate?

"Systems are in place to pay for performance and penalize hospitals for excessive readmissions." Health care trends already include paying for performance (HEDIS, HCAHPS) and penalizing hospitals for excess readmissions. In the United States, private insurers dominate over public, unlike in most countries. The United States is first in health care spending worldwide, and it is estimated that 20% of the gross domestic product will be spent on medical services by 2021.

A nurse is conducting a class about health care trends for a group of newly graduated registered nurses at the community hospital. Which of the following six trends stated by the nurse reflects the Institute of Medicine's (IOM) focus?

"The system should be safe, effective, efficient, patient centered, timely, and equitable." A safe, effective, efficient, patient-centered, timely, and equitable system is what is envisioned by the IOM. A bureaucratic, government-driven, illness-focused system is not advocated by the IOM.

It is recommended that a client go to a convalescent center upon discharge following a minor stroke. The client says, "I don't want to go anywhere, I want to go home." Which information should the nurse offer?

"You will only stay until you are well enough to go home." Those entering convalescent centers remain only until they have recovered. The nurse should explain this even though the client does have the right to refuse. There is no indication that the client will not be able to care for oneself again. There is a difference between a convalescent center and a nursing home.

Which client would a nurse correctly refer to Medicare services?

A 66-year-old client with diabetes Medicare is a federal health care plan for individuals over the age of 65. An individual with a disability might be referred to Medicare, but other federal organizations must be involved for this to occur. A low-income family with infants needing immunizations would be referred to Medicaid. The client with cancer in this question is not noted to be over age 65.

The nurse is caring for several clients with chronic conditions that need to be evaluated for long-term care. After evaluating each client, the nurse determines which client is most appropriate to receive long-term care?

A client who suffered a stroke who has mobility issues and problems completing activities of daily living (ADLs). Long-term care facilities provide health care and help with daily living for people of any age who are physically or mentally unable to care for themselves independently. This care may extend for periods ranging from days to years. A client who suffered a stroke who has mobility issues and problems completing ADLs is an appropriate client to receive long-term care services. A client requiring medication monitoring needs primary health care, not long-term care. The client with a back injury and physical therapy needs treatment and outpatient therapy, not long-term care. The client diagnosed with pneumonia requiring mechanical ventilation requires acute care, not long-term care.

A nurse demonstrates understanding of Healthy People 2020: Understanding and Improving Health by supporting which statement?

A client's health is affected by social, economic, and political factors. People believe "quality of life" to be synonymous with a healthy community. There is growing recognition that to achieve the goals of Healthy People 2020: Understanding and Improving Health, a model inclusive of multiple health determinants is needed. Clinical care has typically focused on diagnosing and treating symptoms. Understanding health in relation to personal behaviors, social factors, and other determinants provides a holistic context and not a quick resolution of needs. As an example, it is important to know an individual's access to a grocery store with fresh fruits and vegetables to comprehend the client's nutritional needs. To affect social, economic, political, and educational health determinants, health initiatives are more effective if they are based in the community and incorporate community collaboration. While physical therapy can be helpful for a client in the home, it does not have a basis for the community emphasis in Health People 2020.

The nurse is providing care to several clients. For which client should the nurse include secondary care in the nursing plan of care?

A middle-aged client who presents with new-onset angina A middle-aged client who presents with new-onset angina requires a referral to a cardiologist and probably additional testing. Secondary care occurs when the primary caregivers refer clients for consultation and additional testing, such as with the referral of a client to a cardiac catheterization laboratory. The remainder of the clients require only primary care.

When conducting an education program for a group preparing for retirement, the nurse would include information about applying for Social Security benefits and Medicare insurance. The nurse would include in the education that Medicare is a federally funded insurance program which bases the fee for payment on what?

A prospective payment plan based on a predetermined fixed cost The nurse must understand that Medicare is a federal insurance program for older adults. It is based on a prospective payment plan that pays a predetermined fixed amount for in-hospital costs. Medicare does not pay physician groups and is not for indigent older adults. Retrospective payment plans pay for services after they have been received.

Which is an emerging trend in health care delivery?

Active involvement of consumers Trends in health care delivery include the active involvement of consumers, continuing nursing shortage, increased complexity of client care, and a technology explosion. Other trends include changing demographics, increasing diversity, globalization of economy and society, increasing costs of health care, and the effects of health policy and regulation.

Which government policy addresses penalizing hospitals for readmissions of clients with certain diagnoses within 30 days after discharge?

Affordable Care Act As part of the Affordable Care Act, hospitals may accrue penalties for readmissions of clients with certain diagnoses within 30 days of discharge. To improve client outcomes and avoid penalties, care transitions are being implemented to improve the continuity of services from hospital to home and to reduce readmissions. A collaborative discharge plan that includes the client's primary care services as well as any home care is essential for transitional care to be successful. The Americans with Disabilities Act (ADA) became law in 1990. The ADA is a civil rights law that prohibits discrimination against individuals with disabilities in all areas of public life, including jobs, schools, transportation, and all public and private places that are open to the general public. American Nurses Association (ANA) bylaws are rules established by the ANA to govern members of the ANA. The National Commission for Minorities is an organization based in the country of India.

A home health care nurse is providing visits for a 65-year-old widower who needs some assistance with performing activities of daily living (ADLs) but is living independently. What option might the nurse recommend that would enable the client to maintain independence for as long as possible?

Aging in place The nurse might recommend for this client aging in place. In this type of care, clients remain in their homes or move to a living space, such as an apartment, while they are still physically able to care for themselves, and then have access to services that are a part of the health care community as needed. Someone who is living independently but only needs some assistance with ADLs would not be placed in a long-term care facility or transitional subacute care facility. A medical home is an enhanced model of primary care that provides whole-person, accessible, comprehensive, ongoing, and coordinated client-centered care.

Which therapist is most likely to focus on teaching a client to hold a toothbrush with an adaptive device and brush the teeth?

An occupational therapist An occupational therapist assists physically challenged clients to adapt to limitations and use a variety of adaptive devices and strategies in carrying out activities of daily living. The occupational therapist is the health care professional who would assist the client in using an adaptive device to brush the teeth. A speech therapist assists clients with speaking and swallowing problems. A physical therapist seeks to restore function or prevent further disability after an injury or illness. A respiratory therapist is trained in techniques that improve lung function and oxygenation.

Which scenario is using a prospective payment plan to reimburse for services?

An older adult client is admitted to the hospital and treated for pneumonia. The hospital is reimbursed based on a predetermined fixed price. A prospective payment system uses financial incentives to decrease total healthcare charges by reimbursing hospitals on a fixed rate basis. Reimbursement is based on the diagnostic-related group (DRG). Therefore, the scenario in which the hospital is reimbursed is an example of a prospective payment plan. The other scenarios demonstrate other types of payment plans.

The nurse is providing care to several clients on a medical-surgical unit. For which client's plan of care should the nurse include information regarding extended care?

An older adult client who fell at home and required a hip replacement Extended care meets the health needs of clients who no longer require acute hospital care but require rehabilitation and skilled nursing care, such as an older adult following a hip replacement surgery, who may need additional assistance with mobility and more time for physical therapy before being ready to be discharged home. The other clients do not require, or would not benefit from, extended care.

Which statement accurately reflects the findings of the 1999 Institute of Medicine report, "To Err Is Human"?

Anywhere from 44,000 to 98,000 people are estimated to die in U.S. hospitals each year as a result of preventable medical errors. The report states that anywhere from 44,000 to 98,000 people are estimated to die in U.S. hospitals each year as a result of preventable medical errors. It is the fragmented, rather than centralized, nature of health care that has contributed to medical errors. The report recommends a national, rather than local or regional, focus on leadership to improve outcomes. Voluntary reporting is encouraged.

During a hospice visit, the client's spouse suddenly begins to cry and says, "I am so tired. I just can't do this anymore. I am not getting to sleep and I just eat sandwiches when I can." What is the nurse's best intervention?

Arrange for short-term inpatient care for the client. This spouse is exhausted and needs respite care. The hospice nurse can arrange for short-term inpatient care for the client so that the spouse can rest. The other options will not be effective for exhaustion.

Which statement is most accurate in discussing the difference between nursing care provided in the acute care setting and that provided in the home care setting?

Both settings focus on the holistic care of an individual. Although the setting for care and the type of intervention may change, the nursing focus is always the same: the holistic care of an individual. Wherever the nurse practices, the primary concern is to provide for health care that focuses not only on physiologic needs but also psychosocial and spiritual needs of the person in relation to the environment. Both care settings require the participation of the client, but only the home care setting requires the participation of the client's family. The home care setting can be initiated before the client returns to full function. Both settings focus on the client's needs.

Unlicensed assistive personnel (UAP) include which workers?

Certified nursing assistants, orderlies, attendants, and technicians Certified nursing assistants, orderlies, attendants, and technicians are considered UAP. Volunteers, admission clerks, and housekeepers, although invaluable to hospital function, are not UAP.

Which statement regarding spiritual care providers in hospitals is most accurate?

Clergy, lay volunteers, and those with advanced spiritual care degrees can serve on the spiritual care team at hospitals. Clergy, lay volunteers, and providers with advanced spiritual care degrees provide spiritual care to clients, families, and members of the interdisciplinary team. Spiritual care can be provided by non-clergy, but lay volunteers are not typically the primary spiritual care providers in most hospitals.

A nurse working for a home health agency is scheduled to evaluate a client with worsening heart failure to determine whether the client is a candidate for the new "Hospital at Home" program. Which statement accurately reflects an outcome for this program?

Clients in the "Hospital at Home" program have been found to require shorter lengths of stay than when admitted to the acute care setting. Clients who receieve care in their own homes, surrounded by familiar family and friends, have been found to recover more quickly than those in inpatient acute care settings. The other statements are not accurate.

A new nurse is considering getting a job in either an acute care setting or a home care setting. Which statement about these care settings is most accurate?

Clients play a large role in helping themselves in the home care setting. In nursing practice in the hospital, client needs include physiologic monitoring, complete or partial personal care, exercise, nutritional support, pain management, treatment and medication administration, anticipatory guidance, counseling, and education, which requires the complexity of health care teams. Nurses are involved in a variety of teams and care needs are complex. Clients are not encouraged to help each other in the acute care setting. Because of the trend toward shorter lengths of stay, the clients are discharged to home, where they may be more involved in helping meet their own care needs. Communication skills are critical in both the acute care and home care settings.

Based on the Patient Protection and Affordable Care Act (ACA), nurses are to assume an important new role in health care. Which is an example of this new role?

Collaborating with all agencies to provide for the client's home health needs As the various components of the ACA are phased in, nurses have begun to play an influential role in the implementation of new health policy. The newest opportunity is collaborating with all agencies to provide for the client's home health needs. Nurses have already been involved in screening individuals for type 2 diabetes mellitus and providing postoperative teaching for ostomy care. Nurses recheck paperwork for consent prior to surgery, but this is not just limited to nurses. Other health care providers also review consent prior to surgery.

In providing nursing care, it is most important to perform which action?

Coordination of care with the health care team Nurses have moved from simply observing and giving prescribed medications to coordinating clinical information for the entire health care team.

Nurses in various health care settings provide services to prevent the fragmentation of care that is occurring as a health care trend in today's society. What role of the nurse is most important in preventing this effect?

Coordinator of care The most important role of the nurse in preventing fragmentation of care would be coordinator of care. Care coordination is the deliberate organization of client care activities between two or more participants (including the client) involved in a client's care to facilitate the appropriate delivery of health care services. The roles of care provider, counselor, and educator are all important roles, but the priority role is as the coordinator of care.

An ambulatory care center that facilitates socialization and provides health-related services to seniors who are unable to fully care for themselves is best known by what name?

Day care center Day care centers provide these services to senior citizens. Ambulatory care is an overarching category of care centers and clinics that can include psychosocial, physical, and mental health care. Hospital at home care and extended care centers are for patients who require more complex care than can be provided in a day care center.

What are chief tasks of the home health care nurse? Select all that apply.

Developing a nursing care plan Providing client education and counseling Providing continuity of care Administering medications The chief tasks of the home health care nurse are developing a nursing care plan, providing client education and counseling, providing continuity of care, and administering medications. The home health care nurse is not tasked with collecting payment for nursing care. The home health care nurse is not tasked with providing for a dignified death at home. This is the role of the hospice nurse.

The growth in home health care is largely attributed to which factor?

Early discharge of clients from the hospital setting Home health care is one of the most rapidly growing areas of the health care system. The prospective payment system of reimbursement encourages early discharge from the hospital and has created a new, acutely ill population that needs skilled nursing care at home. Though some nurses may desire to work in the community and hospitals may have a shortage of nurses, these are not the primary factor related to the increase in home health care. It is not that hospitals cannot care for an increasing number of clients so much as it is that they will not be reimbursed by payers for costs associated with longer client stays; thus, they are motivated to discharge clients earlier even though clients are often not yet ready to provide all of their own needed care, leading to the need for and prevalence of home health care.

A nurse has an older adult home care client who lives alone with no family nearby. On a recent visit, the nurse notices that his clothes are very loose, and he has difficulty letting the nurse leave when the visit is ending. After talking with him, the nurse learns that he has not been cooking for himself and he can't get to the grocery store easily. What service could the nurse suggest as an immediate response until a long-term plan can be formed?

Enroll the client in Meals on Wheels. The best option that can be arranged quickly is to enroll the client in Meals on Wheels, a voluntary agency. The other responses may be helpful in later planning for a long-term situation.

What role does the nurse assume when gathering information for a community assessment?

Epidemiologist A nurse epidemiologist gathers and analyzes qualitative and survey data to describe and understand unique communities. A medical transcriptionist is one who converts live or recorded speech dictated by a physician, nurse, or other helath care provider to a written document via typing. An oncologist is a specialist in the study of cancer and cancer treatment. A thanatologist is a specialist in the study of death.

The goals of health care reform include which?

Focusing on cost containment with improved access and quality of services for everyone The goals of health care reform focus on cost containment, improved access, and increased quality of services for all citizens. Health care reform seeks to increase, rather than decrease, the number and quality of services provided.

A hospitalized client with advanced metastatic lung cancer states, "I want to go home. I don't have much time left. I want to be with my family." Which type of care referral by the nurse is most appropriate?

Hospice Hospice is a program of palliative and supportive care services providing physical, psychological, social, and spiritual care for dying people, their families, and other loved ones, often provided in the client's own home. Because the client is near the end of life, hospice care would be the most appropriate referral. Respite care is a type of care provided for caregivers of homebound ill, disabled, or older adults, to give them some time away from the responsibilities of day-to-day care. This type of care would not be appropriate for this client because the client has been hospitalized and wants to be with family. Extended-care services provide medical and nonmedical care for people with chronic illnesses or disabilities. Extended care occurs outside the home, however, which is not what the client desires. Palliative care evolved from the hospice experience but also exists outside of hospice programs. It is not restricted to the end of life and can be used from the point of initial diagnosis. Palliative care, which may be given in conjunction with medical treatment and in all types of health care settings, is patient- and family-centered care that optimizes the quality of life by anticipating, preventing, and treating suffering. Palliative care alone is not as appropriate as hospice care in this case, given that the client is near the end of life.

A nurse is researching health care in rural areas. Based on a 2013 U.S. Subcommittee on Primary Health and Aging, which statement regarding access to primary health care is correct?

One in five Americans lives in an area without adequate access to primary health care due to a shortage of primary care providers. One in five Americans lives in an area without adequate access to primary health care due to a shortage of primary care providers. It is estimated that about 45,000 people die each year in the United States due to access issues. Seven percent of the nation's medical school graduates choose a primary care career. Currently, one in three physicians specializes in primary care.

A nurse is providing supportive care to a client diagnosed with a terminal illness who is not expected to live past the next 3 months or so. The nurse is likely working in which setting?

Hospice care Hospice is a program of palliative and supportive care services providing physical, psychological, social, and spiritual care for dying people, their families, and other loved ones. The client must have a serious, progressive illness with a life expectancy of 6 months or less. Palliative care evolved from the hospice experience but also exists outside of hospice programs. It is not restricted to the end of life and can be used from the point of initial diagnosis. Respite care is a type of care provided for caregivers of homebound ill, disabled, or older clients. The main purpose is to give the primary caregiver some time away from the responsibilities of day-to-day care. Parish nursing is an expanding area of specialty nursing practice that emphasizes holistic health care, health promotion, and disease-prevention activities. It combines professional nursing practice with health ministry, emphasizing health and healing within a faith community.

Which is the acute care setting for people who are too ill to care for themselves at home, are severely injured, or require surgery?

Hospitals Hospitals are the most appropriate acute care setting for people who are too ill to care for themselves at home, are severely injured, require surgery or complicated treatments, or are having babies. An ambulatory care center, which may be referred to as an outpatient care center, is a medical care facility that provides outpatient services. These include diagnosis, treatment, consultation, and intervention services. Day care centers have a variety of purposes: some care for healthy infants and children whose parents work; some care for children with minor illnesses; some provide a place for older adults to socialize and to receive care while family members work; some provide health-related services and care to people who do not need to be in a health care institution but cannot be at home alone. Primary care is the day-to-day health care given by a health care provider and can be provided in an outpatient facility.

Which cost-cutting measure in health care is most likely to facilitate improved client outcomes?

Improving transitions across settings Improving transitions across settings is most likely to improve client outcomes because it involves better client hand-offs during changes from one level of care to another. DRGs help reduce costs but do not directly improve patient outcomes. Comparative effectiveness analysis encourages the provider to carefully select technologies with cost in mind. Capitation and managed care may actually decrease positive client outcomes if there is too much emphasis on cost cutting.

Which is a current trend in health care consumers?

Increased knowledge of health care Explanation: Health care consumers (clients) are increasingly knowledgeable about health, prefer to control and make decisions about their own health, and want to be active participants in planning and implementing their health care. Consumers of health care services are better educated about the services they require and the services that are available, largely because so much health information is available on the Internet. Clients are also concerned about access to services, the cost of those services, and the quality of the care received. Consumers are questioning escalating costs and the proliferation and duplication of services. Consumers have become actively involved in the administration of health care facilities and have helped develop standards for care, client rights, and cost-containment measures as protection for clients when they enter a health care setting.

A nurse whose priority tasks include conducting health assessments, teaching health promotion, such as smoking cessation, eating sensibly, using safety equipment, exercising regularly, caring for minor accidents and illnesses, and making referrals for more serious health problems is likely a healthcare team member in which setting?

Industry The tasks noted are part of the routine practice of an industrial-based nurse. School, homeless shelter, and crisis intervention (mental health) nurses share some similar tasks, but reasonably ensuring the use of safety equipment is most likely to occur in industry.

A hospital system has adopted the Institute for Healthcare Improvement's "Triple Aim" dimensions and has surveyed nurses for planning ideas. Which strategies will help the hospital comply with this framework? Select all that apply.

Make results of quality studies available to nurses in a timelier manner. Create outreach education programs to improve the overall health of the community served. Reduce redundancy in diagnostic tests. Explanation: The Triple Aim framework has three dimensions: 1) improving the client experience of care (including satisfaction and quality); 2) improving the health of populations; and 3) reducing the per capita cost of health care. Making quality information available more quickly would encourage nurses to change practices that result in poorer quality. Reducing redundancy would reduce per capita costs. Educating the public would eventually increase the health of the population. Doing away with client satisfaction surveys would make satisfaction data untrendable. There is no indication that increasing staff salaries would help meet these goals.

A nurse is conducting a presentation for a local community group about health care services available in the community. When describing voluntary agencies, which agency would the nurse include? Select all that apply.

Meals on Wheels American Heart Association American Lung Association Community agencies are often nonprofit voluntary agencies. They are financed by private donations, grants, or fundraisers (although some may charge minimal fees). Examples of volunteer agencies are Meals on Wheels, the American Heart Association, and the American Lung Association. The Centers for Disease Control and Prevention and the Indian Health Service are part of the Public Health Service, a federal health agency.

The nurse understands that a diagnostic-related group is one of the reimbursement strategies in a prospective payment system. The diagnostic-related group is a part of which health care system?

Medicare The federal government implemented a system of prospective payment in 1983 for people enrolled in Medicare. A prospective payment system uses financial incentives to decrease total health care charges by reimbursing hospitals on a fixed rate basis. Reimbursement is based on the diagnostic-related group, which is a classification system used to group clients with similar diagnoses. Medicaid provides health care through funds obtained from federal, state, and local sources. In capitation strategy, a preset fee per member is paid to a health care provider, regardless of whether the member requires services. AmeriCare provides health care services through employers.

The implementation of diagnosis-related groups (DRGs) by Medicare in 1983 affected hospitals in which way?

Medicare pays only the amount of money preassigned to a treatment for a diagnosis. The implementation of DRGs by Medicare in 1983 resulted in a system in which health care providers receive a fixed payment for services provided that is predetermined by the medical diagnosis or specific procedure, rather than the actual cost of hospitalization and care. The plan pays only the amount of money preassigned to the treatment for a diagnosis. If the cost for hospitalization is greater than that assigned, the hospital must absorb the additional cost. If the cost is less than that assigned, the hospital makes a profit. Medicare is federally funded, and benefits may change annually according to decisions related to the federal budget. Part A of Medicare, which pays most inpatient hospital costs, is paid by the federal government. Part B, which is voluntary, is paid by a monthly premium and covers most outpatient costs.

A middle-aged couple is considering enrolling in a long-term care insurance plan. What will this insurance cover?

Nursing home and home care services Long-term care insurance plans cover a variety of services, such as nursing home care and home care, as well as services that help prevent the institutionalization of older, debilitated, and chronically ill people. Adult day care centers and respite care are also services often covered by such a plan. Pharmaceutical costs and inpatient and outpatient services are covered in the elder years by Medicare.

A nurse is helping a client choose a new health care plan. The client states a preference being able to choose a physician. Which plan would be the best option for this client based on the stated preferences?

PPO Preferred provider organizations (PPOs) allow a third-party payer (agencies that pay health care providers for services provided to people, such as a health insurance company) to contract with a group of health care providers to provide services at a lower fee in return for prompt payment and a guaranteed volume of clients and services. The client may choose to use a physician within the PPO for a lower service fee or choose a provider outside the PPO and pay a higher service fee. A point of service (POS) plan is a mix between an HMO and PPO, but the client usually does not have the ability to choose the primary health care provider. Health maintenance organizations (HMOs) are prepaid, group-managed care plans that allow subscribers to receive all the medical services they require through a group of affiliated providers. The client would not be able to choose the provider in most HMOs. Long-term care (LTC) is not a type of health care plan.

Which are priority skills for nurses working in ambulatory mental health centers?

Possessing strong communication and counseling skills and being familiar with community resources Nurses who work in mental health agencies must possess strong communication and counseling skills and be familiar with community resources. Maintaining function and independence is more typical of a nurse working in an extended care facility. Administering medications and treatments, conducting health screenings, teaching, and counseling are associated with clinics that treat physiological alterations. Working collaboratively with physicians who approve care protocols is indicative of an advanced practice registered nurse working in a rural clinic.

A nurse has very strong client education skills. In which health care setting would the nurse make best use of these skills?

Primary care center Primary health care provides care for common health problems and provides preventative measures. Client education is a common part of the nurse's activities in this setting. While teaching does (and should) occur in the other environments, the nurse does not have the opportunity to see the client repeatedly to teach and reinforce teaching.

A client who is affluent and places a high priority on maintaining freedom to choose which physicians and health care services the client uses would most likely be best served by which group plan?

Private insurance Private insurance is normally more expensive than alternative group plans such as PPOs, HMOs, and LTC insurance. However, it typically allows the policyholder to have significantly more autonomy related to which practitioners and services to use. Long-term care insurance is an insurance product that helps pay for the costs associated with long-term care. PPO plans allow the client to visit whatever in-network physician or health care provider desired without first requiring a referral from a primary care physician. An HMO gives the client access to certain doctors and hospitals within its network. A network is made up of providers who have agreed to lower their rates for plan members and also meet quality standards. But unlike PPO plans, care under an HMO plan is covered only if the client sees a provider within that HMO's network.

A nurse is volunteering time at a homeless shelter in an urban setting. What service provided by the nurse would be of benefit to this population of clients?

Providing an educational program about nutrition The homeless are at increased risk for illness or injury because of factors such as exposure to the elements, exposure to violence, drug and alcohol addiction, poor nutrition, poor hygiene, and overcrowding. Services provided by nurses in homeless shelters include immunizing children, teaching pregnant women, treating infections and illnesses, referring for diagnosis and treatment of sexually transmitted infections, and providing information about maintaining health. It is not in the nurses role to provide financial assistance or to provide emergency services. Prescriptive ability is outside of the realm of practice for a RN unless the nurse is advanced practice.

What nursing function would be most commonly found in an ambulatory care facility?

Providing direct client care Ambulatory care centers and clinics (agencies that deliver outpatient medical care) may be located in hospitals, may be a freestanding service provided by a group of health care providers who work together, or may be managed by an advanced practice registered nurse. Although a nurse may serve as an administrator or manager in such a facility, the nursing function most commonly found in this setting is providing direct client care. Educating individuals or groups would be a nursing function more commonly found in a primary care facility. Assessing the home environment would be a nursing function more commonly found in home health care.

During a home care visit to a home-bound older client, the client's spouse, who is the caregiver, verbalizes anger, fatigue, and sleeplessness. Which recommendations by the nurse would be most effective in relieving caregiver role strain?

Respite care Hospice, voluntary services, and palliative care would all be helpful to the client and spouse, but only respite care directly provides the spouse with a break from caregiving duties.

Which statement regarding pay for performance is most accurate?

Quality of care is measured and used to evaluate hospitals and other providers and to award reimbursement. In pay for performance, quality of care is measured and used to evaluate hospitals and other providers and to award reimbursement. Financial incentives are offered to health care providers for achieving certain clinical measures established by the payer, not client objectives. These clinical measures include not only delivery efficiencies, improved quality, and patient safety, but also submission of data to the payer. Pay for performance is not limited to any particular hospital size

Who provides care in the primary nursing model?

Registered nurses In the primary nursing model, one registered nurse (RN), frequently with the assistance of a licensed practical or vocational nurse or nursing assistant, is responsible for providing (either directly or by delegating to others) all care for a group of clients throughout their stay in a hospital unit or department. Nursing students, who are not yet licensed, cannot independently provide care to clients. Nursing assistants assist RNs in providing care to clients, but the RN is responsible for the client's care. An RN need not have a Master's degree to provide care in the primary nursing model.

A nurse recommends palliative care for a client who is being discharged following a diagnosis of cancer. What is the chief focus of this type of care?

Relief from physical, mental, and spiritual distress The chief focus of palliative care is relief or management from physical, mental, and spiritual distress. The goal of palliative care is to prevent and relieve suffering by early assessment and treatment of pain and other physical problems (such as difficulty breathing, nausea, fatigue, and problems with sleeping). Like hospice care, palliative care is provided by an interdisciplinary team. Physical rehabilitation and occupational therapy would be the goal of home care, moving the client from the functional level at discharge from the hospital to a higher level of functioning, closer to the level prior to the hospitalization. Provision of a dignified death experience would be the goal of hospice.

The nurse is providing care for a client who has a tracheostomy and whose pulse oximeter has recently alarmed, showing the client's oxygen saturation to be 77%. The nurse has repositioned the client and applied supplementary oxygen, interventions that have raised the client's oxygen levels to 80% and have somewhat decreased his work of breathing. The client is not in immediate distress, and his level of consciousness remains high. The nurse should page which practitioner?

Respiratory therapist A respiratory therapist is an expert in lung function and oxygenation whose expertise is needed in the care of this client. Because the client is not experiencing severe distress or respiratory arrest, the nurse is justified in foregoing contact with the physician in the short term. A physical therapist or occupational therapist is not likely able to provide needed interventions at this time.

A nurse is providing care to a client recently admitted to the health care facility for treatment of an infection. The client experienced a traumatic brain injury several months ago that resulted in paralysis of both lower extremities and difficulty swallowing and speaking. The client's spouse is the primary caregiver. The client's spouse says to the nurse, "It's been really tough this last month caring for my spouse. Even though I have an aide who comes in to help for a couple of hours a week, I'm just spent, physically and emotionally." A referral for which service would be appropriate?

Respite care Respite care is a type of care provided for caregivers of homebound ill, disabled, or older clients. The main purpose is to give the primary caregiver some time away from the responsibilities of day-to-day care. Although parish nursing and palliative care may be helpful in providing the spouse with support, it would not necessarily provide the respite needed. Parish nursing emphasizes holistic health care, health promotion, and disease-prevention activities and combines professional nursing practice with health ministry, emphasizing health and healing within a faith community. Palliative care evolved from the hospice experience but also exists outside of hospice programs. It is not restricted to the end of life and can be used from the point of initial diagnosis. Palliative care, which may be given in conjunction with medical treatment and in all types of health care settings, is client- and family-centered. Hospice care is typically provided to clients with less than 6 months to live. There is no indication that the client is at this stage.

The family of a terminally ill client asks the nurse about respite care. What should the nurse educate the family about regarding respite care?

Respite care is often provided by volunteers. Respite care is covered only by Medicare, not by Medicaid. It does not require a referral by the physician. It is primarily nursing assistants and volunteers who provide the care, in either the client's home or an adult day care center.

A client with a recent total knee replacement who is about to be discharged home with home health services states, "I think it is too soon for me to go home." What should the nurse explain to the client is the primary reason for the implementation of this level of care?

Sophisticated technology generally allows client care to be managed safely in the home environment. Although the payment reimbursement system encourages early discharge when safe to do so, it is not generally a requirement. Home health agencies are able to provide many services, but these services are not necessarily more easily done in the home than in an acute care setting. It is not necessarily true that client education is more easily done in the home nor is there evidence in this scenario that the care required by this client at home is teaching. The best answer is that technology allows select clients to receive quality care in the home.

Which statement most accurately reflects the intent of secondary care?

Specialists provide psychiatric care, same-day surgery, and general hospital care. Secondary care involves some specialists who provide care, such as psychiatric care and same-day surgery, generally in the hospital setting. Common health problems are generally consigned to primary care in an outpatient setting. Complex, rare disease states are cared for in tertiary care centers.

The nurse is a member of the multidisciplinary team in a large primary healthcare setting. The nurse understands that which healthcare team member is responsible for a client's swallow evaluation following a cerebral vascular accident?

Speech pathologist/therapist It is within the speech pathologist's/therapist's scope of practice to conduct a swallow evaluation for a client but outside the scope of the occupational therapist, the physical therapist, and the physician assistant.

A nurse is a member of an interdisciplinary team providing home health care to a client who was discharged home after experiencing a stroke. The client has been receiving services to assist with swallowing. The nurse would collaborate with which member of the team to discuss the client's progress?

Speech therapist A speech therapist diagnoses and treats swallowing problems in clients who have had a head injury or a stroke. A physical therapist seeks to restore function or to prevent further disability in a client after an injury or illness. Occupational therapists evaluate the client's functional level and teach activities to promote self-care in activities of daily living. Social workers assist clients and families in dealing with the social, emotional, and environmental factors that affect their well-being.

A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Since the early introduction of stroke rehabilitation, the client has seen significant improvements in both medical status and activities of daily living (ADLs). This morning, however, the nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the client's chest reveals the presence of coarse crackles. Which practitioner should the nurse consult with to obtain a swallowing assessment?

Speech therapist The diagnosis and treatment of dysphagia (swallowing problems) are within the purview of speech therapists. The physician should be made aware and respiratory therapy may be involved with assessing and promoting the client's oxygenation, but swallowing assessment is a task most often performed by a speech therapist.

Which are helpful tips for a nurse who has been active in health care policy and reform give to a nurse who is interested in becoming active in this area? Select all that apply.

Stay up to date regarding new pending legislature that will determine nursing practice. Join and participate in nursing associations. Advocate for the rights of all people in health care. Some of the things that the nurse can do to be involved in health care policy and legislature are to stay informed about current issues and pending legislation, write or e-mail members of Congress to support legislation to improve nursing and client care, belong to and participate in nursing organizations, document the outcomes of nursing care and develop a database to influence health care costs and quality of care, participate in efforts to design and implement innovative health care delivery models, be a leader in local, state, and national nursing and consumer groups, and advocate for the rights of all people for equal, affordable, accessible, and knowledgeable health care. Although working overtime whenver asked and reporting workers who may be impaired may be good things for the nurse to do, they do not relate to health care policy and reform.

You are the nurse employed in an acute care hospital. The head nurse states that you will be caring for 12 clients with the help of two nurse assistants. This is considered to be what type of nursing care delivery?

Team nursing Team nursing is the provision of care with a nurse supervising the work of one or more aides.

Which statement is true when comparing home care with acute care?

The nurse is the guest in the client's home. An essential difference in home care versus acute care is that the home care nurse is a "guest" in the client's home. In the home, clients and families retain the power and control that they give to providers in other settings. Nurses in the home usually work as members of a therapeutic team that includes the client and other members of the health care team working collaboratively. The client does not direct the education of the caregivers.

The nurse is providing care to an older adult client approaching discharge following a surgical procedure to repair a fractured hip. The client requires continued skilled nursing care and physical therapy to improve mobility. When planning care for this client, which prescription should the nurse anticipate?

Transfer to an extended care facility The nurse should anticipate that this client will be transferred to an extended care facility, which meets the health needs of clients who no longer require acute hospital care but require rehabilitation and skilled nursing care. This client does not meet the requirements for home health care, hospice care, or an intermediate care facility.

A nurse is considering accepting a new position in an ambulatory care center. What roles does the nurse understand are likely in this setting? Select all that apply.

Triaging walk-in clients Teaching clients about wellness and illness Assisting with minor surgical procedures Performing physical assessments Explanation: Prioritizing patient care tasks, teaching, assisting in surgery, and performing physical assessments are all within the registered nurse's (RN) scope of practice. Prescribing medications is outside the RN scope of practice.

A home health nurse is scheduled to make a visit to a client who was discharged from the hospital yesterday following an appendectomy. The nurse understands that the scope of practice for a home health nurse allows the nurse to perform which psychomotor tasks?

Wound care, medication administration, teaching, and ensuring a reasonably safe environment Nurses who provide care in the home make assessments (including of home safety) and provide physical care (including wound care), administer medications, teach (including dietary instruction), and support family members. They also collaborate with other health care providers, such as physicians, physical therapists, occupational therapists, respiratory therapists, and social workers, to plan and provide client care. Home health nurses may not prescribe medications.

An example of primary health care is:

a hearing screening in the school setting. Primary prevention or primary health care involves health promotion, basic care, and health prevention, including screening clients to detect disease early and prevent it from developing further. Care of a client in the intensive care unit or on rehabilitation is secondary care. Diagnostic testing for HIV/AIDS is tertiary care.

Medicare part A is:

an insurance program that pays a set amount based on the diagnosis and approved care for in-hospital services. The nurse must understand that Medicare is a federal insurance program for older people. Medicare part A is based on a prospective payment plan that pays a predetermined fixed amount for in-hospital costs. Medicare part A is admininstered federally, not locally. Medicare part B, not A, covers outpatient physician visits, medications, and home health. Medicare part A does not limit enrollees to certain providers with a group plan. Medicaid, not Medicare, is a federally funded public assistance program for low-income people.

One of the primary advantages of the managed care model is:

economic, quality care. The primary advantage of the managed care model is provision of high-quality care in the most efficient and economic manner. Managed care often results in decreased client satisfaction due to a lack of choice of health care provider. Manged care is provided by a diverse health care team with many different specialties and areas of care represented, not an all-RN staff or only one distinct area of care.

The Nursing Agenda for Health Care Reform (American Nurses Association [ANA]) identifies the recipients of health care. This reform's main focus is on:

health promotion. Recent health care reform efforts, in particular the Affordable Care Act (ACA), have made strides toward realizing nursing's vision of health care that is focused on health promotion, delivered where the individual needs it, and focused on wellness rather than disease management; however, there is much work still to be done as the effects of the ACA become known. Health care is currently focused on high-quality disease management and technology and not the prevention of disease. Accurate assessments are already part of the admission process in all health care settings.

In the 1980s, the nursing care delivery model shifted from a team nursing model to a:

primary nursing model. In the 1980s, the nursing care delivery model shifted from a team nursing model, in which a team of nurses collaboratively provide care to a given client during a stay, to a primary nursing model, in which one registered nurse (RN) is responsible for providing all care needed by a given client during the client's stay (either directly or by delegating to others). The managed care model is an approach to health care delivery that seeks to contain the costs of health care while providing quality care. Modular nursing is similar to team nursing except that the clients assigned to a given team of nurses are grouped according to geographical location on the unit. A clinical specialist is a nurse who has additional training in a medical specialty, such as cardiology.

What is one of the most significant trends in health care today?

shift from hospitals to community-based care The shift to community-based care is related to the public's desire to participate more actively in health care decisions, issues, and choices.