Chapter 12: Collaborative Practice and Care Coordination Across Settings

A nurse, preparing for a patients discharge after surgery, is teaching the patients wife to change the dressing. How can the nurse be certain the wife knows the procedure?

A) Tell the wife exactly how to do it.
B) Give the wife information about supplies.
C) Have the wife demonstrate the procedure.
D) Ask another nurse to reinforce teaching.
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Terms in this set (95)
A nurse, preparing for a patients discharge after surgery, is teaching the patients wife to change the dressing. How can the nurse be certain the wife knows the procedure?

A) Tell the wife exactly how to do it.
B) Give the wife information about supplies.
C) Have the wife demonstrate the procedure.
D) Ask another nurse to reinforce teaching.
C) Have the wife demonstrate the procedure.
Advocacy
A supporting role that the nurse plays in the protection of a patient's rights.
Care Coordination
Specifically putting together patient care activities that involve the patient and one or more people that in turn give the patient effective care. Right care, right time
Care coordinator
The individual caring for the patient who identifies health goals and provides a way for the patient to meet those goals.
Care transition
A continuous process in which a patient's care changes from being provided in one setting of care to another
Ex. inpatients to outpatients.
Collaborative practice
Involves different health care individuals from different disciplines working together with patients, families and other individuals to provide the highest quality of care possible.
Community based care
Care that is provided to people who live within a specific region and or who have common needs; designed to meet the needs of people as they move between and among health care settings
Continuity of care
Proper care given to the patient before during and after the patients time in a health care setting.
Discharge planning
-should begin when client is admitted (with the exception of LTC)
-assess if the client will be able to return home and/or if they will need assistance at home
-assess residence to see if adaptations or specific equipment will be necessary
-make referral to social worker if needed
-communicate client health status and needs to community service providers
-if client chooses to leave before discharged, notify provider and have pt sign off with an AMA form
Home health care
care that takes place in a person's home
ISBARQrevised SBAR approach that includes Introduction, Situation, Background, Assessment, Recommendations, and Question and answerMedication reconciliationA procedure to maintain an accurate and up-to-date list of medications for all patients between all phases of health care delivery.nurse navigatorclinically trained nurse responsible for the identification and removal of barriers to timely and appropriate treatmentPatient handofftransferring responsibility for a patient from one caregiver to another with the goal of providing timely, accurate information about a patient's plan of care, treatment, current condition, and anticipated changesPatient navigatorA person whose role is to remove obstacles that patients face in accessing and receiving treatmentSBARSituation Background Assessment RecommendationWhich of the following phrases best describes continuity of care? A) focusing on acute care in the hospital B) serving the needs of children C) facilitating transition between settings D) providing single-episode care servicesC) facilitating transition between settingsWhich of the following roles of the nurse are most important in providing continuity of care to patients? Select all that apply. A) teacher B) collaborator C) mentor D) advocate E) role model F) researcherA) teacher B) collaborator D) advocateA focus of healthcare today is community-based care. What is community-based care? A) care provided to patients within a defined geographic area B) a focus on providing appropriate care for mental health C) a focus on the health of the community D) an emphasis on population-based careA) care provided to patients within a defined geographic areaWhich of the following is a result of the effect of increasing healthcare costs on hospital admissions? A) decreased length of hospital stay B) decreased number of surgeries C) increased hospital admissions D) fewer surgeries in ambulatory centersA) decreased length of hospital stayWhich of the following nursing diagnoses would be appropriate for almost all patients entering a healthcare setting? A) Impaired Elimination B) Dysfunctional Grieving C) Fatigue D) AnxietyD) AnxietyA nurse is admitting an older woman (Grace Staples) to a long-term care facility. How should the nurse address the woman? A) We will just call you Grace while you live here. Okay? B) I know you have lots of grandchildren, Grandma. C) What name do you want us to use for you? D) I think you will enjoy living here, SweetieC) What name do you want us to use for you?How can a nurse best provide care to patients whose cultural and religious backgrounds are different from the nurses? A) ignore differences and treat everyone the same B) respect values and beliefs even if they differ from the nurses beliefs C) convince patients to change to the nurses beliefs D) refuse to care for patients with different beliefsB) respect values and beliefs even if they differ from the nurses beliefsA nurse is admitting a patient to the hospital for surgery. Which of the following pieces of information must be obtained from the patient? Select all that apply. A) address B) date of birth C) admitting physician D) symptoms experienced E) Immunizations F) religious preference G) admitting diagnosisA) address B) date of birth C) admitting physician F) religious preference G) admitting diagnosisWhich of the following is the major goal of ambulatory care facilities? A) to save money by not paying hospital rates B) to provide care to patients capable of self-care at home C) to perform major surgery in a community setting D) to perform tests prior to being admitted to the hospitalB) to provide care to patients capable of self-care at homeA nurse is preparing a room for a new patient. Which of the following is an accepted guideline for this activity? Select all that apply. A) Position the bed in the highest position for ambulatory patients. B) Open the bed by folding back the top linens. C) Assemble routine equipment and supplies. D) Provide a hospital gown to be worn by the patient at all times. E) If lab work has not been done, provide a container for a clean urine specimen. F) Adjust the temperature to 65F and turn off overhead lights.B) Open the bed by folding back the top linens. C) Assemble routine equipment and supplies. E) If lab work has not been done, provide a container for a clean urine specimen.According to established standards, what healthcare provider should conduct a holistic assessment for all patients admitted to the hospital? A) physician B) admission clerk C) licensed practical nurse D) registered nurseD) registered nurseRegardless of the type of ambulatory care facility, what need is common to all patients cared for? A) referrals B) teaching C) advocacy D) surgeryB) teachingWhat information does HIPAA mandate be given to patients upon admission to a healthcare facility? A) what type of insurance is necessary for care B) who will be providing different types of care C) what different levels of care are provided D) how health information will be usedD) how health information will be usedWhich healthcare provider is responsible for ensuring the room is prepared for admission and the patient is welcomed? A) nursing assistant B) admitting room clerk C) social worker D) nurseD) nurseA patient has suddenly become very ill, and a nurse is transferring him to the intensive care unit (ICU). How does the nurse provide information to ensure continuity of care? A) by giving a verbal report to nurses in the ICU B) by ensuring that the chart and all belongings are moved C) by delegating a nursing assistant to provide information D) by asking the family to provide the informationA) by giving a verbal report to nurses in the ICU The ICU nurse gives a verbal report on the patient's condition and nursing care needs to the nurse on the new unit. This information is not given to a unit secretary, nor is its provision delegated to others. The medical record is transferred with the patient; a copy is not made.A patient is being transferred from a hospital to a long-term care facility. What will happen to the patients medical record (chart)? A) It goes with the patient to the facility. B) It remains in the hospital records. C) It is shredded by special personnel. D) The original and a copy go with the patient.B) It remains in the hospital records.At what point during hospital-based care does planning for discharge begin? A) on admission to the hospital B) after the patient is settled in a room C) immediately before discharge D) after leaving the hospitalA) on admission to the hospitalWhat is the rationale for conducting discharge planning? A) to ensure the best possible care in the acute care setting B) to provide a means of documenting nursing care C) to enlist family members in providing home care D) to ensure patient and family needs are met consistentlyD) to ensure patient and family needs are met consistentlyWhat is required of a patient who leaves the hospital against medical advice (AMA)? A) nothing, the hospital has no legal concerns B) full reimbursement of any medical expenses C) providing contact phone numbers if needed D) signing a form releasing legal responsibilityD) signing a form releasing legal responsibilityWhich of the following patients would not be discharged to be cared for by the family? A) a patient who needs sterile dressings changed B) a patient with a feeding tube in place C) a patient receiving IV medications D) a patient who lacks knowledge of the treatment planD) a patient who lacks knowledge of the treatment planA single parent age 17 years, with one child and pregnant with a second, has the mental age of a 12-year-old. The home care nurse's greatest concern in caring for this client should be the client's ability to do which? A) Cognitively understand how to care for the children B) Bond with the children C) Receive financial aid D) Physically perform care needed by the childrenA) Cognitively understand how to care for the childrenAn 82-year-old client is being discharged from the hospital following bowel resection. The client lives alone and the client's family is out of town. Which factor will have the greatest effect on the client's home care management?support systemIn 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? A) Making home health care referrals B) Providing client education C) Developing goals with the client D) Assessing the client's needs and identifying problemsProviding client educationThe nurse is working with a client's family and social worker to select a home health care agency. Which question does the nurse state should be the family's priority when interviewing potential home health agencies? A) Does the agency meet uniform standards for licensing, certification, and accreditation by state agencies and/or federal programs? B) Is the facility listed as a government-approved facility with no infractions? C)Does the agency provide care to facilitate transition to a hospital? D)How does the agency train employees for accountability and do they require a background check?Does the agency meet uniform standards for licensing, certification, and accreditation by state agencies and/or federal programs? The most important information a family should obtain before selecting a home health agency is determining whether the agency meets uniform standards for licensing, certification, and accreditation. Inquiring about infractions listed with government organizations is important but would not be a family's priority question. Home health agencies facilitate transition from hospital to home, not home to hospital. Home care agencies typically require background checks and conduct training of employees. While these requirements can and should be confirmed by the family, it is not the most important information to obtain.Which are examples of subjective client information? Select all that apply. Marital status and occupation Vital signs, height, and weight Smoking and alcohol history Findings on palpation of the abdomen List of medicationsMarital status and occupation Smoking and alcohol history List of medicationsIn 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. Use a multimedia strategy that combines animation with narration. Explain the procedure clearly and slowly while providing multiple opportunities for the daughter to ask questions. Provide explicit written and verbal instructions and ask the daughter to explain back to the nurse how to perform the procedure.Demonstrate and explain the procedure and then have the daughter perform it. All steps of a procedure such as a dressing change should be demonstrated, practiced, and provided in writing. The client or caregiver should then perform the procedure or treatment in the presence of the nurse to demonstrate understanding and ability to carry out the procedure. This is more likely to facilitate success than providing a passive multimedia resource, explaining, or providing written instructions alone without reciprocal demonstration.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 chronic nursing shortage The focus on treatment of disease The preference of nurses to work during the day instead of evening or night shifts The discharge home of clients who are more critically illThe discharge home of clients who are more critically illThe 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 was nauseated following a cholecystectomy. A client who lives alone with few close friends or family. A client whose spouse is debilitated and requires care. A client who takes oral medications for recently diagnosed diabetes mellitus.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 measure should a home health care nurse integrate into routine practice to minimize the potential for lawsuits? Perform thorough, accurate, and timely documentation. Apply more conservative interventions than those used in a hospital setting. Integrate the client's learning needs and goals into plans of care. Have the client sign a waiver prior to the entry phase of a visit.Perform thorough, accurate, and timely documentation.A client is having an increasing amount of difficulty caring for oneself in the home alone. The client states to the nurse, "I need more help. What am I going to do?" Which action would be the most appropriate for the nurse to take? Have the social worker visit the client to discuss care options. Have the physical therapist help the client with rehabilitation. Have the home health aide increase visits for bathing the client. Have the occupational therapist assess for the client's need for adaptive devices.Have the social worker visit the client to discuss care options.A client diagnosed with terminal leukemia is receiving home health care services to assist in the client's care. After assessing the client, the home health care nurse determines that the client is unable to afford needed medical supplies. Which is the best strategy for the nurse to implement to assist the client? Discuss the client situation with the provider for possible therapies that are more cost-conscious. Enlist the services of the client's family for some components of care, such as dressing changes and physical therapy. Refer the client to a local religious organization or non-profit agency for support. Refer the client to a social worker to determine eligibility for assistance.Refer the client to a social worker to determine eligibility for assistance.Which role is the home health nurse exhibiting when demonstrating how to suction the oropharynx of the client? Caregiver Advocate Educator Care coordinatorEducatorA 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 don't know why I survived and not my best friend." It is most important for the home care nurse to encourage the client to: communicate these feelings to family and friends. allow a religious leader in the client's life to visit. be certain that the client's educational needs are being met. increase the client's activity to assist in coping.communicate these feelings to family and friendsPublic health nursing is the branch of nursing that: provides primary care to individuals. assesses individuals for community care. administers care for a defined geographic community. provides health care for the community.provides health care for the community.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 the nurse's visits. Which aspect of the admission process does this represent? Establishing rapport and showing willingness to listen Clearly defining the purpose and expectations of the admission Documenting the procedure Assisting in participation of the care-related decisionsClearly defining the purpose and expectations of the admissionThe 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 Caregiver Client advocate Coordinator of servicesClient and family educatorIt is important for home health care nurses to remember which point? The nurse is the primary caregiver. The nurse is the guest in the client's home. Rehabilitation is the major client goal. The nurse should act as a counselor and advisor.The nurse is the guest in the client's home.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 the surroundings, call system, bathroom, bedside supplies, and where to place clothes. The priority nursing action is to: obtain the physician's orders. call the dietary department to get breakfast for the client. gather information and complete the admission database. ask the nursing assistant to obtain vital signs.gather information and complete the admission database.On admission to the hospital, each client is asked whether the client has a living will or a durable power of attorney. If not, the admitting staff person provides a sample form to the client if wanted. The purpose of this inquiry is to determine: what the client wants to have happen during the hospitalization. how the client feels about being resuscitated and maintained on life support if this is necessary. whether the client has a document describing wishes for care when the client is no longer able to make decisions. previous decisions made regarding whom to contact should the client die in the hospital.whether the client has a document describing wishes for care when the client is no longer able to make decisions.The nurse understands that planning for discharge actually begins at admission to the facility. The purpose of discharge planning is best described as: decreasing stress for client and family members. providing continuity of care that is goal directed. ensuring client safety and health maintenance. promoting less dependence on others.providing continuity of care that is goal directed.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. A nurse manager ensures that the client navigates the health care system with a maximum of efficiency and a minimum of frustration to avoid causing the client to feel isolated or abandoned. The primary nurse delegates client care to other health care professionals but is consulted when new problems develop or the plan of care requires modifications. A nurse practitioner monitors the client's care and makes referrals for consultation and additional testing.The case manager identifies dates when oxygen should be discontinued, bronchodilators changed to self-administered inhalers, and antibiotics changed from intravenous to oral treatment.A nurse who is a discharge planner in a large metropolitan hospital is preparing a discharge plan for a patient after a kidney transplant. Which actions would this nurse typically perform to ensure continuity of care as the patient moves from acute care to home care? Select all that apply. Performing an admission health assessment Evaluating the nursing plan for effectiveness of care Participating in the transfer of the patient to the postoperative care unit Making referrals to appropriate facilities Maintaining records of patient satisfaction with services Assessing the strengths and limitations of the patient and familyEvaluating the nursing plan for effectiveness of care Making referrals to appropriate facilities Assessing the strengths and limitations of the patient and family The primary roles of the discharge planner as patients move from acute to home care are evaluating the nursing plan for effectiveness of care, making referrals for patients, and assessing the strengths of patients and their families. Although in smaller facilities a discharge planner may perform an admission health assessment and assist with patient transfers, it is not the usual job of the discharge planner. In most facilities, maintaining records of patient satisfaction is the role of the public relations manager or office manager.A discharge nurse is evaluating patients and their families to determine the need for a formal discharge plan or referrals to another facility. Which patients would most likely be a candidate for these services? Select all that apply. An older adult who is diagnosed with dementia in the hospital A 45-year-old man who is diagnosed with Parkinson's disease A 35-year-old woman who is receiving chemotherapy for breast cancer A 16-year-old boy who is being discharged with a cast on his leg A new mother who delivered a healthy infant via a cesarean birth A 59-year-old man who is diagnosed with end-stage bladder cancerAn older adult who is diagnosed with dementia in the hospital A 45-year-old man who is diagnosed with Parkinson's disease A 59-year-old man who is diagnosed with end-stage bladder cancer The patients who are most likely to need a formal discharge plan or referral to another facility are those who are emotionally or mentally unstable (e.g., those with dementia), those who have recently diagnosed chronic disease (e.g., Parkinson's disease), and those who have a terminal illness (e.g., end-stage cancer). Other candidates include patients who do not understand the treatment plan, are socially isolated, have had major surgery or illness, need a complex home care regimen, or lack financial services or referral sources.A home health care nurse is scheduled to visit a 38-year-old woman who has been discharged from the hospital with a new colostomy. Which duties would the nurse perform for this patient in the entry phase of the home visit? Select all that apply. Collect information about the patient's diagnosis, surgery, and treatments. Call the patient to make initial contact and schedule a visit. Develop rapport with the patient and her family. Assess the patient to identify her needs. Assess the physical environment of the home. Evaluate safety issues including the neighborhood in which she lives.Develop rapport with the patient and her family. Assess the patient to identify her needs. Assess the physical environment of the home. In the entry phase of the home visit, the nurse develops rapport with the patient and family, makes assessments, determines nursing diagnoses, establishes desired outcomes, plans and implements prescribed care, and provides teaching. In the pre-entry phase of the home visit, the nurse collects information about the patient's diagnoses, surgical experience, socioeconomic status, and treatment orders. In the pre-entry phase, the nurse also gathers supplies needed, makes an initial phone contact with the patient to arrange for a visit, and assesses the patient's environment for safety issues.A hospital nurse is admitting a patient who sustained a head injury in a motor vehicle accident. Which activity could the nurse delegate to licensed assistive personnel? Collecting information for a health history Performing a physical assessment Contacting the health care provider for medical orders Preparing the bed and collecting needed suppliesPreparing the bed and collecting needed supplies The nurse may delegate preparation of the bed and collection of needed supplies to unlicensed personnel but would perform the other activities listed.A nurse is preparing an infant and his family for a hernia repair to be performed in an ambulatory care facility. What is the primary role of the nurse during the admission process? To assist with screening tests To provide patient teaching To assess what has been done and what still needs to be done To assist with hernia repairTo assess what has been done and what still needs to be done Although all the actions may be performed by the ambulatory care nurse, it is the nurse's primary responsibility to assess what has been done and to tailor the care plan to the patient's needs. Screening tests and teaching are usually completed before the patient enters an ambulatory care facility.Which statement or question MOST exemplifies the role of the nurse in establishing a discharge plan for a patient who has had major abdominal surgery? "I'll bet you will be so glad to be home in your own bed." "What are your expectations for recovery from your surgery?" "Be sure to take your pain medications and change your dressing." "You will just be fine! Please stop worrying.""What are your expectations for recovery from your surgery?" The purpose of planning for continuity of care, commonly referred to in hospitals and community facilities as discharge planning, is to ensure that patient and family needs are consistently met as the patient moves from a care setting to home. Essential components of discharge planning include assessing the strengths and limitations of the patient, the family or support person, and the environment; implementing and coordinating the care plan; considering individual, family, and community resources; and evaluating the effectiveness of care. Answers a and c are not MOST reflective of the role of the nurse in discharge planning, although teaching and communication are elements of this process. The statement "You will just be fine! Please stop worrying." is a cliché and should not be used.A nurse is counseling an older woman who has been hospitalized for dehydration secondary to a urinary tract infection. The patient tells the nurse: "I don't like being in the hospital. There are too many bad bugs in here. I'll probably go home sicker than I came in." She also insists that she is going to get dressed and go home. She has the capacity to make these decisions. What is the legal responsibility of the nurse in this situation? To inform the patient that only the primary health care provider can authorize discharge from a hospital To collect the patient's belongings and prepare the paperwork for the patient's discharge To request a psychiatric consult for the patient and inform her PCP of the results To explain that the choice carries a risk for increased complications and make sure that the patient has signed a release formTo explain that the choice carries a risk for increased complications and make sure that the patient has signed a release form The patient is legally free to leave the hospital AMA; however, patients who leave the hospital AMA must sign a form releasing the health care provider and hospital from legal responsibility for their health status. This signed form becomes part of the medical record.A nurse ensures that a hospital room prepared by an aide is ready for a new ambulatory patient. Which condition would the nurse ask the aide to correct? The bed linens are folded back. A hospital gown is on the bed. Equipment for taking vital signs is in the room. The bed is in the highest position.The bed is in the highest position. A properly prepared hospital room includes a bed in the lowest position for an ambulatory patient, an open bed with top linens folded back, routine equipment and supplies and special equipment and supplies assembled, and the physical environment of the room adjusted.A nurse decides to become a home health care nurse. Which personal qualities are key to being successful as a community-based nurse? Select all that apply. Making accurate assessments Researching new treatments for chronic diseases Communicating effectively Delegating tasks appropriately Performing clinical skills effectively Making independent decisionsMaking accurate assessments Communicating effectively Performing clinical skills effectively Nurses working in the community must have the knowledge and skills to make accurate assessments, work independently, communicate effectively, and perform clinical skills accurately. Community-based nurses may be researchers and occasionally delegate care, but these are not key qualities for this type of nursing.A client living alone has degenerative joint disease, hypertension, and neuropathy. It is difficult for the client to bathe, and the client's blood pressure is unstable. Which type of care would this client benefit from most? Acute care Ambulatory care Home care Respite careHome care Home health care services are delivered to persons at home who are recovering from illness, are disabled, or are chronically or terminally ill and need various services to progress, maintain function, or perform their activities of daily living. Acute and ambulatory care are delivered on a short-term basis, and respite care's focus is on the caregiver.When doing discharge planning for an older adult client who had a stroke, what is the nursing priority? Involve the family in discussing when the client will go home. Help the client after discharge to establish goals. Realize that goals may not be met after discharge. Plan reachable goals with the client and family.Plan reachable goals with the client and family.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." "You need a graduate degree to specialize in home health care." "Each team member works independently of other team members." "It requires that you have high-level critical care skills.""The client and family are in control of the setting, not the nurse."Which type of home healthcare agency is a local health department? Institution-based agency Private, proprietary agency Official or public agency Private not-for-profit agencyOfficial or public agency Health departments are public agencies supported through tax dollars and benefit the community in which they are located. Private not-for-profit agencies are supported by donations, endowments, charities, and insurance reimbursement. Private, proprietary agencies are usually for-profit organizations governed by individual owners or national corporations. Institution-based agencies operate under a parent organization, such as a hospital.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 The increase in the incidence and prevalence of infectious diseases The need for decreased financial expenditures Changes to the structure of Medicare and MedicaidThe change to shorter hospital staysWhich are components of the nursing case management process? Select all that apply. Filing and completing paperwork Making referrals Monitoring medical progress Prescribing medications Driving a client to appointments CoordinatingCoordinating Making referrals Monitoring medical progress Filing and completing paperworkWhich is the largest single source of reimbursement for home health care services? Medicaid Medicare Private insurance Client's self-payMedicareA 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 uses the SBAR technique during the handoff. The nurse prepares the new room for the client. The nurse asks the other health care professionals if they have any questions. The nurse determines who should be involved in the handoff communication.The nurse prepares the new room for the client.A registered nurse is providing community-based health care for a client diagnosed with early onset dementia. Which strategy is best for the nurse to employ to facilitate the family participating in the client's care? Create a care plan based on the client's requests and inform the family of the client's wishes. Provide referrals for health care professionals to perform the client's activities of daily living (ADLs). Reinforce the care plan to the family if it is determined the client is not properly cared for. Encourage active participation of the client and family in health care decisions.Encourage active participation of the client and family in health care decisions.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? Clinician Nurse practitioner Caregiver CoordinatorHome careWhen preparing to transfer an older adult client back to the long-term care facility where the client has been for several years, it is the primary responsibility of the nurse to: ensure that the current health state of the client is maintained. discuss the return to familiar surroundings with the client. provide for the coordination and continuity of care by the health care providers. communicate to the next of kin so they are aware of the transfer.provide for the coordination and continuity of care by the health care providers.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: restrain the client until a social worker can explain the possible results of the client's actions. call the client's family and have them discharge the client. notify the physician, discuss the outcomes of the client's decision, and have the client sign a release form. call for a psychological consultation to see whether the client is mentally stable.notify the physician, discuss the outcomes of the client's decision, and have the client sign a release form.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 need this information for billing purposes." "I am trying to build a relationship with you." "I have to ask because it is required in every referral to home care." "I want to understand what your desires are.""I want to understand what your desires are."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 Social worker Physical therapist Home health aideOccupational therapist The occupational therapist can evaluate the functional level of the client and teach activities to promote self-care in activities of daily living, such as cooking. The physical therapist provides direct care, such as muscle-strengthening exercises, gait training, and massage. The home health aide assists clients with hygiene and performing light housekeeping. The social worker provides assistance with health care finances and in securing equipment and supplies. Chapter 12: Collaborative Practice and Care Coordination across Settings - Page 281The nurse manager of the acute care unit has decided to implement a team nursing approach for client care. One of the staff members asks, "Will we each take care of our own clients?" What is the appropriate response by the manager? "I will plan the care based on the client's diagnosis or type of case." "One person will provide skilled care, one will give medications, and one will help with hygienic needs." "The care will be divided and the registered nurse (RN) will have a licensed practical/vocational nurse (LPN/LVN) and unlicensed assistive personnel (UAP) to provide care together." "Each registered nurse (RN) will be assigned a client and be responsible for planning and evaluating care.""The care will be divided and the registered nurse (RN) will have a licensed practical/vocational nurse (LPN/LVN) and unlicensed assistive personnel (UAP) to provide care together."Which action must the nurse perform on discharge of a client from an acute care facility? Sending the client's records to the attending physician Coordinating future care for the client Writing a discharge order for the client Writing any orders for future home visits that may be necessary for the clientCoordinating future care for the clientA group of nursing students is discussing reasons why they would like to become home health nurses after licensure. The nursing instructor facilitating this discussion would offer additional information when which statement is made? Select all that apply. "I like the creativity that is possible when working in home health. " "I would like to spend more time talking with clients than doing skills." "I would like to depend on my own knowledge when treating clients." "I don't think fast enough to work in a hospital." "Home health nursing will work into my schedule better.""I would like to spend more time talking with clients than doing skills." "I don't think fast enough to work in a hospital." Nurses who work in home health must have excellent care skills, including the ability to think and act quickly if necessary. Assessment skills are paramount, but the nurse must also possess excellent technical skills. The autonomy of depending on one's own knowledge and the creativity possible when working in home health are two reasons many nurses are drawn to the specialty. It is also often possible to arrange scheduling so that it better fits into the nurse's personal life. Chapter 12: Collaborative Practice and Care Coordination across Settings - Page 267A nurse is using the 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 began complaining of severe chest pain, rating it as a 10 on a scale of 1 to 10, after walking back from the bathroom." "The client had an exploratory laparotomy 2 days ago and was progressing well. The vital signs were stable until this episode." "This event seemed to come out of the blue. The client denies any history of heart disease but does take a baby aspirin each night." "The client is scheduled for a cardiac catheterization in about an hour and needs monitoring every 15 minutes.""The client is scheduled for a cardiac catheterization in about an hour and needs monitoring every 15 minutes." SBAR provides a framework for communication between members of the health care team about a client's condition. It is an easy and focused way to set expectations for what will be communicated between members of the team, which is essential for developing teamwork and fostering a culture of client safety. S stands for the situation (complaint, diagnosis, treatment plan, and client's wants and needs); B stands for background (vital signs, mental and code status, list of medications, and lab results); A stands for assessment (current provider's assessment of the situation); and R stands for recommendations (identification of pending lab results and what needs to be done over the next few hours, along with other recommendations for care).An 82-year-old client is being discharged from the hospital following a bowel resection. The client lives alone and the client's family is out of town. Which factor will have the greatest effect on the client's home care management?Support system Explanation: A client who has had bowel surgery, particularly an older client, would require much assistance in performing activities of daily living while recovering. Because this client lives alone and has no family available, the client may not be able to stay at home and may need to be placed in a facility to provide adequate support. A strong support system could meet the client's needs for medication management, transportation, and psychosocial support. A lack of a support system would likely mean that none of these other needs would be met. Thus, the client's support system is the most important factor related to home care management.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 Explanation: Regardless of the number of providers for home health care, the responsibility for care coordination remains with the registered nurse, not with the social worker, chaplain or minister, or home health care aide.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 purchases, offering rationale for our choices." "Before our next meeting, each of us will ask the nurses on the unit what their priority purchase would be." "I am willing to prioritize the list if someone else will write the rationale." "Once we have completed the list and rationale, I will compile our recommendations for us all to sign before submission." "When I got this assignment, they said something about deciding what equipment to purchase next year.""Once we have completed the list and rationale, I will compile our recommendations for us all to sign before submission." "Before our next meeting, each of us will ask the nurses on the unit what their priority purchase would be." "Our goal is to prioritize this list of potential equipment purchases, offering rationale for our choices." The most important component of team structure is to have a common goal. The goal of this group is to list potential equipment purchases with rationale. The second-most important component of team structure is to have clear roles and responsibilities. The direction by the nurse for the members to query nurses on each unit is an example of establishing clear roles and responsibilities. Teams also should hold themselves mutually accountable for achieving the goal, such as by having all the team members sign the recommendation. The work should be done by the team, not by just one or two members, as in the option about one nurse prioritizing the list and another writing rationale. Clarity and specificity are important in communicating the purpose of the team, both of which are lacking in the statement, "they said something about deciding what equipment to purchase next year."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 the surroundings, call system, bathroom, bedside supplies, and where to place clothes. The priority nursing action is to: obtain the physician's orders. call the dietary department to get breakfast for the client. gather information and complete the admission database. ask the nursing assistant to obtain vital signs.gather information and complete the admission database.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 don't know why I survived and not my best friend." It is most important for the home care nurse to encourage the client to: allow a religious leader in the client's life to visit. be certain that the client's educational needs are being met increase the client's activity to assist in coping. communicate these feelings to family and friends.communicate these feelings to family and friends. The home health care nurse can assist in coordinating care needs and encouraging family, teachers, schoolmates, and friends to understand the client's struggles and help support the client's needs. Encouraging the client to allow a religious leader to visit may or may not be appropriate, depending on the client's beliefs. Ensuring that the client's educational needs are being met does not address the client's emotional and spiritual needs. Because the client has fractures and multiple trauma injuries, increasing activity is not likely to be an option and, in any case, would not directly address the client's emotional and spiritual concerns. Chapter 12: Collaborative Practice and Care Coordination across Settings - Page 283A home health care nurse develops a client's individualized plan of care during the: entry phase. referral process. pre-entry phase. discharge planning.entry phase.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 physician The case manager The registered nurse The hospital discharge plannerThe physicianWhich is the primary goal of home health care? Functioning within limitations Treatment of illness Provision of palliative care Prevention of diseaseFunctioning within limitationsThe 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 Intravenous therapy Pain management HomemakingHigh-rise toilet seatWhat is the priority nursing responsibility when transferring a client from one unit in the hospital to another? Bring all of the client's belongings to the new unit. Transport the completed client chart to the receiving unit. Provide a verbal report of the client's status to the admitting nurse. Help the client become familiar with the new unit.Provide a verbal report of the client's status to the admitting nurse. Explanation: Although the nurse may transport belongings and the chart, the priority responsibility for the nurse is the verbal report/communication with the nurse on the new unit. It is not the task of the nurse who brings the client to the new unit to orient the client.Home health care nurses are required to complete the Outcome and Assessment Information Set (OASIS) by which entity? Medicare Medicaid Any third-party payer Any insurance companyMedicare Explanation: OASIS provides standardized guidelines for admission and care, as well as a national database for evaluation, reimbursement, and quality improvement. The OASIS system of data collection is required by Medicare, not by Medicaid, insurance companies, or any other third-party payer.