Chapter 2: Patient Care Settings

MULTIPLE CHOICE

	1.	While the home health nurse is doing the entry to service assessment on a home-bound patient, the wife of the patient asks whether Medicare will cover the patient’s ventilator therapy and his insulin injections. The nurse responds:
1.	“Yes, Medicare will cover both the ventilator therapy and the insulin injections.”	
2.	“No, Medicare will not cover either of these ongoing therapies.”	
3.	“Medicare will cover ventilator therapy but not insulin injections.”	
4.	“Medicare will cover ongoing insulin therapy, but not a highly technical skill such as ventilator therapy.”	

ANS:	3
Medicare will cover skilled nursing tasks such as ventilator therapy, but common tasks that can be taught to the family or the patient are not covered.

PTS:	1	DIF:	Cognitive Level: Application	REF:	16
OBJ:	3	TOP:	Medicare Coverage for Home Health	
KEY:	Nursing Process Step: Implementation		
MSC:	NCLEX: Safe, Effective Care Environment	

	2.	The wife of a patient asks the nurse whether her husband would be considered for placement in a skilled nursing care facility when he is discharged from the general hospital. The patient is incontinent, has mild dementia but is able to ambulate with a walker, and must have help to eat and dress himself. The nurse’s most appropriate reply is:
1.	“Yes, your husband would qualify for a skilled care facility because of his inability to feed and dress himself.”	
2.	“No, your husband’s disabilities would not qualify him for a skilled facility.”	
3.	“Yes, because of his dementia your husband qualifies for placement in a skilled care facility.”	
4.	“Yes, anyone who is willing to pay can be placed in a skilled nursing facility.”	

ANS:	2
Placement in a skilled nursing facility must be authorized by the physician, there must be a clear need for rehabilitation or severe deficits in self-care that have a potential for improvement.

PTS:	1	DIF:	Cognitive Level: Analysis	REF:	14
OBJ:	9	TOP:	Placement Qualifications for Skilled Nursing Facility
KEY:	Nursing Process Step: Implementation		
MSC:	NCLEX: Safe, Effective Care Environment	

	3.	The nurse has noted that a newly admitted resident to an extended care facility stays in her room, does not take active part in activities, and leaves the meal table after having eaten very little. The nurse analyzes this relocation response as:
1.	regression.	
2.	social withdrawal.	
3.	depersonalization.	
4.	passive aggressive.	

ANS:	2
Social withdrawal is a frequent response to relocation.

PTS:	1	DIF:	Cognitive Level: Application	REF:	23
OBJ:	10	TOP:	Relocation Response		
KEY:	Nursing Process Step: Assessment	MSC:	NCLEX: Psychosocial Integrity

	4.	The nurse clarifies to a new client in a rehabilitation center that “rehabilitation” means that the client will:
1.	return to his previous level of functioning.	
2.	be counseled into a new career.	
3.	develop better coping skills to accept his disability.	
4.	attain the greatest degree of independence possible.	

ANS:	4
The rehabilitation process works to promote independence at whatever level the patient is capable of achieving.

PTS:	1	DIF:	Cognitive Level: Comprehension	REF:	10
OBJ:	4	TOP:	Rehabilitation Goals		
KEY:	Nursing Process Step: Implementation		
MSC:	NCLEX: Health Promotion

	5.	The nurse assesses a client who needs to be reminded to take premeasured oral medications, wash, go to meals, and undress and come to bed at night, but is considered safe to come and go as he pleases. The nurse determines that the appropriate placement would be in a facility that features:
1.	skilled care.	
2.	intermediate care.	
3.	sheltered housing.	
4.	domiciliary care.	

ANS:	4
Domiciliary care provides room, board, and supervision, where residents may come and go as they please. Sheltered housing does not provide 24-hour care.

PTS:	1	DIF:	Cognitive Level: Application	REF:	21
OBJ:	4	TOP:	Levels of Care, Criteria for Domiciliary Residence
KEY:	Nursing Process Step: Assessment	
MSC:	NCLEX: Safe, Effective Care Environment	

	6.	The nurse is making a list of the members of the rehabilitation team so that the different types of services available to patients may be taught to a group of families. Which of the following lists should be used?
1.	Physical therapist, nurse, family members, personal MD	
2.	Occupational therapist, dietitian, nurse, patient	
3.	Rehabilitation MD, laboratory technician, patient, and family	
4.	Vocational rehabilitation specialist, patient, psychiatrist	

ANS:	1
The rehabilitation team usually consists of all of the choices except the laboratory technician, dietician, and psychiatrist. (The mental health role is represented by the psychologist.)

PTS:	1	DIF:	Cognitive Level: Comprehension	REF:	20
OBJ:	4	TOP:	Rehabilitation Team Members	
KEY:	Nursing Process Step: Planning	
MSC:	NCLEX: Safe, Effective Care Environment	

	7.	The nurse explains the level of disability to a patient who was injured in a construction accident that resulted in the loss of both his right arm and right leg. Because this has affected his quality of life and ability to return to his previous employment, he would be classified as being disabled at level:
1.	I.	
2.	II.	
3.	III.	
4.	IV.	

ANS:	2
The client is limited in the use of his right arm for feeding himself, dressing himself, and driving his car, which are three main ADLs. He may be able to work if there are workplace modifications.

PTS:	1	DIF:	Cognitive Level: Application	REF:	18
OBJ:	5	TOP:	Levels of Disability		
KEY:	Nursing Process Step: Implementation		
MSC:	NCLEX: Safe, Effective Care Environment	

	8.	The nurse explains that in 1990, when the Americans with Disabilities Act was passed, it extended many services for the disabled, such as:
1.	coverage for the rehabilitation of disabled WWI servicemen by providing job training.	
2.	extension of protection to the disabled in the military sector, such as wheelchair ramps on military bases.	
3.	extension of protection to the disabled in private areas, such as accessibility to public restaurant bathrooms and telephones.	
4.	affording the disabled the full access to all health care services.	

ANS:	3
The ADA of 1990 extended the previous legislative acts of 1920, 1935, and 1973. This act now covers private sector individuals and public businesses in particular.

PTS:	1	DIF:	Cognitive Level: Comprehension	REF:	19
OBJ:	6	TOP:	Americans with Disabilities Act (ADA) of 1990
KEY:	Nursing Process Step: Assessment	
MSC:	NCLEX: Safe, Effective Care Environment	

	9.	The frail patient asks the nurse if a bath is to be given this morning. The best reply by the nurse that would encourage independence and give the patient the most flexibility would be:
1.	“Based on your room number, you get bathed on Monday, Wednesday, and Friday. Today is Tuesday.”	
2.	“If you want to eat breakfast in the dining room with the others, you may sponge yourself off in your bathroom.”	
3.	“When your daughter comes this evening, ask her if she can give you a bath then.”	
4.	“I will bring a basin of water for a sponge off for right now. After breakfast, we will talk about a bath schedule.”	

ANS:	4
The resident should be provided as much flexibility as possible and support for independence.

PTS:	1	DIF:	Cognitive Level: Application	REF:	24
OBJ:	11	TOP:	Maintenance of Autonomy in Extended Care Facility
KEY:	Nursing Process Step: Implementation		
MSC:	NCLEX: Safe, Effective Care Environment	

	10.	A computer programmer who has lost both legs is being retained by his employer, who has made arrangements for a ramp and a special desk to accommodate the patient’s wheelchair. This is an example of disability level:
1.	I.	
2.	II.	
3.	III.	
4.	IV.	

ANS:	2
Level II allows for workplace accommodation, which in this case is the desk modification.

PTS:	1	DIF:	Cognitive Level: Analysis	REF:	18
OBJ:	6	TOP:	Reasonable Accommodation	
KEY:	Nursing Process Step: N/A	MSC:	NCLEX: Psychosocial Integrity

	11.	The nurse explains that the law that provides for a partially paralyzed fork lift operator to be retrained by vocational rehabilitation services for less demanding office work is the:
1.	Vocational Rehabilitation Act of 1920.	
2.	Social Security Act of 1935.	
3.	Rehabilitation Act of 1973.	
4.	Americans with Disabilities Act of 1990.	

ANS:	3
The Rehabilitation Act of 1973 provided a comprehensive approach and expanded resources for public vocational training.

PTS:	1	DIF:	Cognitive Level: Analysis	REF:	19
OBJ:	6	TOP:	Rehabilitation Legislation	
KEY:	Nursing Process Step: Implementation		
MSC:	NCLEX: Safe, Effective Care Environment	

	12.	The home health nurse explains that although she performs all the actions below, the only one that is reimbursable under Medicare payment rules is to:
1.	observe a wife clean and change the dressing.	
2.	take a frail couple for a walk to provide exercise.	
3.	watch a patient measure out all medication.	
4.	teach a patient to give herself insulin.	

ANS:	4
Medicare reimburses skilled techniques that are clearly spelled out; these include teaching but not return demonstration-type actions by patient or family.

PTS:	1	DIF:	Cognitive Level: Comprehension	REF:	15
OBJ:	3	TOP:	Medicare Reimbursable Actions	
KEY:	Nursing Process Step: Assessment	
MSC:	NCLEX: Safe, Effective Care Environment	

	13.	A patient with multiple sclerosis must be fed, bathed, and dressed. The nurse assesses the client to be:
1.	disabled.	
2.	disadvantaged.	
3.	handicapped.	
4.	impaired.	

ANS:	4
Feeding oneself, dressing, and bathing are ADLs. The patient is impaired in this regard.

PTS:	1	DIF:	Cognitive Level: Analysis	REF:	17
OBJ:	4	
TOP:	Principles of Rehabilitation; Defining Levels of Loss of Functioning Independently
KEY:	Nursing Process Step: Implementation		
MSC:	NCLEX: Physiological Integrity

	14.	Which of the following was the first law passed to provide for rehabilitation of Americans?
1.	Vocational Rehabilitation Act of 1920	
2.	Social Security Act of 1935	
3.	Rehabilitation Act of 1973	
4.	Americans with Disabilities Act of 1990	

ANS:	1
The U.S. government has passed four pieces of legislation to identify and meet the needs of the disabled, with each one being more inclusive. The first was in 1920.

PTS:	1	DIF:	Cognitive Level: Knowledge	REF:	19
OBJ:	6	TOP:	Rehabilitation Legislation	
KEY:	Nursing Process Step: N/A	MSC:	NCLEX: Psychosocial Integrity

	15.	When their grandmother was admitted to a long-term residential care facility, the family was assured by the admitting nurse that care, in keeping with the concepts of long-term care, would be based on:
1.	how much the resident can do for herself.	
2.	emphasis on maintenance care for incontinence.	
3.	successful adaptation to the regulations of the home.	
4.	maintenance of as much function as possible.	

ANS:	4
Maintenance of function and encouraging autonomy and independence are some of the basic concepts of long-term care.

PTS:	1	DIF:	Cognitive Level: Comprehension	REF:	23
OBJ:	11	TOP:	Principles of Nursing Home Care	
KEY:	Nursing Process Step: Implementation		
MSC:	NCLEX: Safe, Effective Care Environment	

	16.	The nurse assures a 58-year-old diabetic recuperating from a broken hip that funds for his rehabilitation are available from the:
1.	Vocational Rehabilitation Act of1920.	
2.	Rehabilitation Act of 1973.	
3.	Disabled American Veterans Act of 1990.	
4.	Title V, Health of Crippled Americans 1935.	

ANS:	2
Legislation to assist in paying for rehabilitation of those under 65 and who will benefit from vocational rehabilitation including teaching is the Rehabilitation Act of 1973.

PTS:	1	DIF:	Cognitive Level: Application	REF:	19
OBJ:	6	TOP:	Legislation for Funding Health Care		
KEY:	Nursing Process Step: Planning	
MSC:	NCLEX: Safe, Effective Care Environment	

	17.	The nurse describes community health nursing by using the example of:
1.	visiting patients in their home after hospital discharge to assess their personal health status.	
2.	asking a nursing assistant to identify the health services most needed in the client’s personal life.	
3.	meeting with residents of low income housing to identify their health care needs.	
4.	developing a hospital-based home health care service.	

ANS:	3
Community-based nursing looks at identified community needs and providing care at all levels of wellness and illness, whereas community health nursing seeks to provide services to groups to modify or create systems of care.

PTS:	1	DIF:	Cognitive Level: Comprehension	REF:	13
OBJ:	2	
TOP:	Defining Community-Based Nursing versus Community Health Nursing
KEY:	Nursing Process Step: Implementation		
MSC:	NCLEX: Health Promotion and Maintenance

	18.	Home health nurses have some different nursing activities than those of community health nurses. Which of the following describes the home health nurse’s activities?
1.	Conducting health education classes in a senior citizens’ common residence building	
2.	Conducting blood pressure screening on a regular basis at a local mall	
3.	Visiting and assessing the home care and further teaching needs of a recently discharged hospital patient	
4.	Acting as a nurse consultant to a chronic psychiatric ward in a state institution	

ANS:	3
The home health nurse works with individuals in the home; the other descriptors are community nurse activities.

PTS:	1	DIF:	Cognitive Level: Application	REF:	14
OBJ:	1	TOP:	Activities of the Home Health Nurse		
KEY:	Nursing Process Step: Implementation		
MSC:	NCLEX: Safe, Effective Care Environment	

MULTIPLE RESPONSE

	1.	As a home health nurse, the LPN is aware that the care skills that are safe and appropriate to teach family members are (select all that apply):
1.	insulin injection.	
2.	sterile dressing changes.	
3.	venipunctures.	
4.	periodic Foley catheter insertions.	
5.	instillation of eye drops.	
6.	changing dressings on small wounds.	

ANS:	1, 5, 6
Insulin injections, instillation of eye drops, and small wound dressing changes are safe to teach a nonprofessional. Sterile dressings, venipunctures, and insertion of Foley catheters are considered skilled and will be reimbursed by Medicare.

PTS:	1	DIF:	Cognitive Level: Analysis	REF:	16
OBJ:	3	TOP:	Skills Taught by Home Health Nurse	
KEY:	Nursing Process Step: Planning	
MSC:	NCLEX: Safe, Effective Care Environment	

	2.	The Nursing Care Plan of a newly admitted 82-year-old resident to a long-term care facility who has had congestive heart failure and osteoarthritis calls for the documentation of regressive behavior. Of these behaviors observed by the nurse, the ones documented as regression are (select all that apply):
1.	talking nonstop to staff and other residents.	
2.	wets and soils self several times a day.	
3.	wakes in the middle of the night and can’t return to sleep.	
4.	wears the same clothes day after day.	
5.	cries frequently for no apparent reason.	

ANS:	2, 4, 5
Behaviors that are infantile or immature in the absence of dementia are considered regressive. Frequent episodes of crying and inattention to personal hygiene are regressive in nature. Excessive talking and wakefulness may be related to relocation anxiety, but are not regressive.

PTS:	1	DIF:	Cognitive Level: Analysis	REF:	23
OBJ:	10	TOP:	Impact of Relocation		
KEY:	Nursing Process Step: Assessment	MSC:	NCLEX: Psychosocial Integrity

	3.	The nurse explains to the home health client that most quality of care problems are a result of (select all that apply):
1.	client’s noncompliance.	
2.	family’s reluctance to participate in the care.	
3.	inadequate documentation.	
4.	limited funding.	
5.	defective communication between care team members.	

ANS:	3, 5
Inadequate communication and incomplete documentation create most of the quality of care problems.

PTS:	1	DIF:	Cognitive Level: Analysis	REF:	17
OBJ:	1	TOP:	Communication in Home Health Setting	
KEY:	Nursing Process Step: Implementation		
MSC:	NCLEX: Safe, Effective Care Environment	

	4.	The 80-year-old man newly admitted to a long-term care facility has suddenly become incontinent of urine at night. The nurse plans interventions to help restore self-toileting by (select all that apply):
1.	waking the resident every 2 hours and escorting him to the bathroom.	
2.	leaving a night-light on.	
3.	discouraging the use of long-legged pajama bottoms.	
4.	placing a urinal at the bedside.	
5.	keeping the room uncluttered.	

ANS:	2, 3, 4, 5
Proving light in an uncluttered room, encouraging clothing that does not impede self-toileting, and making a urinal available increase independence and alleviate situations that make self-toileting difficult. Waking a resident not only disturbs his or her rest, but increases dependency on the staff.

PTS:	1	DIF:	Cognitive Level: Application	REF:	23
OBJ:	1	TOP:	Independence in Long-Term Care Center	
KEY:	Nursing Process Step: Planning	MSC:	NCLEX: Physiological Integrity

COMPLETION

	1.	The nurse clarifies that an impairment that creates a measurable diminished capacity to work is a ____________________.

ANS:	Disability

PTS:	1	DIF:	Cognitive Level: Application	REF:	17
OBJ:	7	TOP:	Rehabilitation Concepts	
KEY:	Nursing Process Step: Implementation		
MSC:	NCLEX: Health Promotion

OTHER

	1.	The home health nurse, in the home to change a decubitus dressing, notices that the wound has a musky odor and is weepier than the last visit, 2 days ago. Prioritize these nursing interventions for this situation:
1.	Contact the case manager.	
2.	Assess the patient’s entire skin, vital signs, and be prepared to describe the wound findings.	
3.	Cleanse the decubitus area well and redress the wound.	
4.	Chart the appearance of the decubitus completely.	
5.	Assess the client’s mobility.	

ANS:	
2, 3, 5, 4, 1
The decubitus finding is important to communicate to the case manager but not until the nurse at the bedside has fully assessed the patient, signs and symptoms, vital signs, and other areas of change that need to be communicated promptly. Then, the case manager will be able to give directions for further care.

PTS:	1	DIF:	Cognitive Level: Analysis	REF:	17
OBJ:	1	TOP:	Communication Between Home Health Staff
KEY:	Nursing Process Step: Assessment	MSC:	NCLEX: Physiological Integrity

	2.	To teach a family member the skill of injecting insulin effectively, the home health nurse will do which of these? Prioritize these nursing interventions for this situation:
1.	Offer instruction at an appropriate pace.	
2.	Write down the steps of the procedure.	
3.	Assess the level of knowledge of the family member.	
4.	Inquire about the preferred learning style.	
5.	Evaluate the family member’s performance.	

ANS:	
3, 2, 4, 1, 5
Effective teaching depends on assessing the level of knowledge, breaking down the skill in steps, offering instruction in the preferred style, pacing the instruction appropriately, and evaluating the performance.

PTS:	1	DIF:	Cognitive Level: Analysis	REF:	16
OBJ:	1	TOP:	Home Health Teaching	
KEY:	Nursing Process Step: Implementation		
MSC:	NCLEX: Physiological Integrity