Medical Surgical Nursing Single Volume Assessment and Management of Clinical Problems 7th Edition by Sharon L. Lewis -Test Bank A+

$35.00
Medical Surgical Nursing Single Volume Assessment and Management of Clinical Problems 7th Edition by Sharon L. Lewis -Test Bank A+

Medical Surgical Nursing Single Volume Assessment and Management of Clinical Problems 7th Edition by Sharon L. Lewis -Test Bank A+

$35.00
Medical Surgical Nursing Single Volume Assessment and Management of Clinical Problems 7th Edition by Sharon L. Lewis -Test Bank A+
  1. While obtaining a health history from a 68-year-old patient, the nurse learns that the patient takes daily supplements of antioxidants beta carotene, selenium, and vitamin E. The nurse recognizes that the use of these substances in slowing the aging process is related to the biologic aging theory of
a.telomere-telomerase decrease.
b.free radicals.
c.somatic mutation.
d.programmed cell death.

Correct Answer: B

Rationale: Research has focused on the use of antioxidants to slow the oxidative process caused by free radicals. Use of antioxidants is not proposed as a treatment for telomere-telomerase decreases, somatic mutation, or programmed cell death.

Cognitive Level: Application Text Reference: p. 69

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

  1. Which question will provide the most useful information when the nurse is performing a comprehensive geriatric assessment of an older adult who is being assessed for admission to an assisted-living facility?
a.“Do you have a history of heart disease?”
b.“Are you able to prepare your own meals?”
c.“Have you had any recent infections?”
d.“How frequently do you see a doctor?”

Correct Answer: B

Rationale: The patient’s functional abilities, rather than the presence of acute or chronic illness, are more useful in determining how well the patient might adapt to the assisted-living situation. The other questions will also provide helpful information but are not as useful in providing a basis for determining patient needs or for developing interventions for the older patient.

Cognitive Level: Application Text Reference: pp. 71, 77

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

  1. As the home health nurse is teaching a 72-year-old patient who lives alone about a new medication, the patient replies “I just don’t learn new information like I used to.” The nurse will plan to
a.schedule the patient for daily visits for medication administration.
b.teach the patient’s family members to give the medications.
c.spend more time discussing the medications with the patient.
d.tell the patient it is not safe to take medications independently.

Correct Answer: C

Rationale: The process of learning new information is slower in older adults, but there is no indication that the patient will be unable to learn about the new medications. Because the patient is living independently, there is no indication that medication administration needs to be done by the nurse or by family members. There are no data to indicate that self-management of medications by this patient is not safe.

Cognitive Level: Application Text Reference: p. 79

Nursing Process: Implementation

NCLEX: Health Promotion and Maintenance

  1. The home health nurse is developing a care plan for an alert and active 85-year-old patient who takes multiple medications for chronic cardiac and respiratory disease. The patient lives with family members who work during the day. An appropriate nursing diagnosis is
a.social isolation related to weakness and fatigue.
b.caregiver role strain related to need to adjust family employment schedule.
c.risk for injury related to drug-drug interactions.
d.compromised family coping related to the patient’s many care needs.

Correct Answer: C

Rationale: The patient’s age and multiple medications indicate a risk for injury caused by interactions between the multiple drugs being taken and a decreased drug metabolism rate. Because the patient is alert and active, the diagnoses in responses 1 and 4 are not appropriate for the patient or family. There is no indication that the family’s employment schedule should be changed to accommodate the needs of this patient.

Cognitive Level: Application Text Reference: pp. 80-81

Nursing Process: Diagnosis

NCLEX: Health Promotion and Maintenance

  1. To obtain the most complete information when doing an assessment for an 81-year-old patient, the nurse will
a.review the patient’s chart for the history of medical problems.
b.interview both the patient and the primary patient caregiver.
c.use a geriatric assessment instrument to evaluate the patient.
d.ask the patient to write down medical problems and medications.

Correct Answer: C

Rationale: The most complete information about the patient will be obtained through the use of an assessment instrument specific to the geriatric population, which will include information about both medical diagnoses and treatments and about functional health patterns and abilities. A review of the chart, interviews of the patient and caregiver, and written information by the patient will all be included in a comprehensive geriatric assessment.

Cognitive Level: Application Text Reference: p. 77

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

  1. When developing the plan of care for an older adult who is hospitalized for an acute illness, the nurse should
a.use a standardized geriatric nursing care plan.
b.plan for likely long-term-care transfer to allow additional time for recovery.
c.consider the preadmission functional abilities when setting patient goals.
d.minimize activity level during hospitalization.

Correct Answer: C

Rationale: The plan of care for older adults should be individualized and based on the patient’s current functional abilities. A standardized geriatric nursing care plan is unlikely to address individual patient needs and strengths. A patient’s need for discharge to a long-term-care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process.

Cognitive Level: Application Text Reference: pp. 78-80

Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

  1. When caring for an older adult who lives in a rural area, the nurse will plan to
a.assess the patient for chronic diseases that are unique to rural areas.
b.ensure that the patient has transportation to appointments with the health care provider.
c.obtain adequate medications for the patient to last for 4 to 6 months.
d.suggest that the patient move to an urban area for better health care.

Correct Answer: B

Rationale: Transportation can be a barrier to accessing health services in rural areas. There are no chronic diseases unique to rural areas. Because medications may change, the nurse should help the patient plan for obtaining medications through alternate means such as the mail or delivery services, not by purchasing large quantities of the medications. The patient living in a rural area may lose the benefits of a familiar situation and social support by moving to an urban area.

Cognitive Level: Application Text Reference: p. 70

Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

  1. To help prevent drug-drug interactions in an older adult patient taking many medications, the most appropriate instruction by the nurse is,
a.“Do not take any over-the-counter (OTC) drugs with your prescription drugs.”
b.“Be sure to have all of your prescriptions filled at the same pharmacy.”
c.“Bring all the medications, supplements, and herbs that you use to every health care appointment.”
d.“Use a medication reminder system so that you won’t forget to take your medications as scheduled.”

Correct Answer: C

Rationale: The most information about drug use and possible interactions is obtained when the patient brings all prescribed medications, OTC medications, and supplements to every health care appointment. The patient should discuss the use of any OTC medications with the health care provider and obtain all prescribed medications from the same pharmacy, but these interventions alone will not prevent drug-drug interactions between prescribed drugs, OTC drugs, and any herbal supplements. Use of a medication reminder system will help the patient take medications as scheduled but will not prevent drug-drug interactions.

Cognitive Level: Application Text Reference: p. 80

Nursing Process: Implementation

NCLEX: Physiological Integrity

  1. The home health nurse is making an 8:00 AM visit to a confused older patient who lives with a daughter. Which information most indicates a need for further action by the nurse?
a.The patient is unable to remember the nurse’s name.
b.The patient has not yet taken the daily medications.
c.The patient is weaker than on the previous visit.
d.The patient’s daughter asks about respite services.

Correct Answer: C

Rationale: A change in physical status may indicate an acute medical problem such as infection or elder abuse or neglect. Inability to remember caregiver names is not unusual in confused patients and simply indicates a need for reintroduction by the nurse. Because it is early in the day, the patient may take the medications later. The question about respite services does indicate a need for further action, but this would not be as urgent as the need to assess the patient for physiologic changes.

Cognitive Level: Application Text Reference: pp. 71, 73

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

  1. Ageism is an important concept for the nurse to understand because it
a.provides statistical information regarding the older population.
b.promotes consideration of the diversity of the older population.
c.may lead to poorer health care for older individuals.
d.increases social awareness of the needs of older people.

Correct Answer: C

Rationale: Negative attitudes about aging may lead to disparities in the way older patients are treated. The concept does not describe statistics about older individuals; consider the diversity of the older population, or increase the awareness of the needs of the older population.

Cognitive Level: Comprehension Text Reference: p. 67

Nursing Process: Assessment NCLEX: Psychosocial Integrity

  1. An alert and well-oriented 78-year-old patient with multiple health problems rarely gets out of bed and complains of having “no energy” and feeling increasingly weak. The patient has had an 11-pound weight loss over the last year. The nurse should initially
a.ask the patient about daily dietary intake.
b.schedule regular range-of-motion exercise.
c.discuss long-term care placement with the patient.
d.describe normal changes with aging to the patient.

Correct Answer: A

Rationale: In the frail elderly patient, nutrition is frequently compromised, and the nurse’s initial action should be to assess the patient’s nutritional status. Active range-of-motion may be helpful in improving the patient’s strength and endurance, but nutritional assessment is the priority because the patient has had a significant weight loss. The patient may be a candidate for long-term-care placement, but more assessment is needed before this can be determined. The patient’s assessment data are not consistent with normal changes associated with aging.

Cognitive Level: Application Text Reference: p. 71

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

  1. When admitting an 88-year-old patient to the hospital, the nurse should plan to
a.interview the patient before the physical assessment.
b.speak slowly and loudly while facing the patient.
c.determine whether the patient uses glasses or hearing aids.
d.obtain a detailed medical history from the patient.

Correct Answer: C

Rationale: Assistive devices should be in place before assessing the patient to minimize anxiety and confusion. When a patient is acutely ill, the physical assessment should be accomplished first to detect any physiologic changes that require immediate action. Not all older patients have hearing deficits, and it is insensitive of the nurse to speak loudly and slowly to all older patients. To avoid tiring the patient, much of the medical history can be obtained from medical records.

Cognitive Level: Application Text Reference: p. 77

Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

  1. The nurse is planning discharge for an alert, homeless 70-year-old with a chronic foot infection and poorly controlled diabetes. The most appropriate intervention by the nurse is to
a.teach the patient how to assess and care for the foot infection.
b.refer to social services for placement in a low-income assisted living facility.
c.give the patient written information about shelters and meal sites.
d.schedule the patient to return to outpatient services for foot and diabetes care.

Correct Answer: B

Rationale: A common reason for homelessness in older adults is the lack of affordable housing. Assisted-living facilities provide both housing and health care assistance for older adults. Even with appropriate education, a homeless individual may not be able to maintain adequate foot and diabetes care because of a lack of supplies or a suitable place to accomplish care. Older homeless individuals are less likely to use shelters or meal sites. A homeless person may fail to keep appointments for outpatient services because of lack of transportation or inability to keep track of dates or times.

Cognitive Level: Application Text Reference: pp. 70-71

Nursing Process: Implementation NCLEX: Physiological Integrity

  1. The home health nurse is caring for a 71-year-old patient who lives alone and is taking seven different prescribed medications for chronic health problems. The nurse will plan to
a.use a marked pillbox to set up the patient’s medications.
b.discuss the option of moving to an assisted-living facility.
c.call the health care provider about stopping some of the medications.
d.visit the patient daily to administer the medications.

Correct Answer: A

Rationale: The use of medication reminder devices is helpful when older adults have multiple medications to take. There is no indication that the patient needs to move to assisted living. Because the average 70-year-old takes seven medications and the medications have been prescribed for the patient’s health problems, discontinuing the medications is not appropriate. Home health care is not designed for the patient who needs ongoing assistance with activities of daily living (ADLs) or instrumental ADLs (IADLs).

Cognitive Level: Application Text Reference: p. 81

Nursing Process: Planning NCLEX: Physiological Integrity

  1. When assessing a 68-year-old Latina patient who has diabetes, which question will the nurse ask in determining the impact of ethnicity on the patient’s health care choices?
a.“Who helps you with your care at home?”
b.“How do you pay your medical bills?”
c.“What do you think helps people get better?”
d.“Which type of insulin do you use?”

Correct Answer: C

Rationale: This question encourages the patient to discuss any special ethnic beliefs about practices, medications, foods, etc., that might be used to maintain or improve health. The information about who cares for the patient does not address the patient’s health care choices. Ethnicity does not have an impact on how the patient pays health care bills. The type of insulin used is not impacted by ethnicity.

Cognitive Level: Application Text Reference: p. 72

Nursing Process: Assessment NCLEX: Psychosocial Integrity

  1. A 42-year-old who is providing home care for a parent tells the nurse, “I don’t feel comfortable giving Mom her medications yet, but I think I will be able to do it with a little more practice.” Which nursing diagnosis is most appropriate?
a.Caregiver role strain related to inability to safely give medications
b.Anxiety related to lack of confidence
c.Risk for situational low self-esteem
d.Readiness for enhanced therapeutic regimen management

Correct Answer: D

Rationale: The caregiver’s statement indicates an interest in learning the new skill and confidence that it can be learned, consistent with the diagnosis of readiness of enhanced therapeutic management. There is no indication of caregiver role strain, anxiety related to lack of confidence, or low self-esteem.

Cognitive Level: Application Text Reference: p. 73

Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

  1. Which information obtained by the home health nurse when making a visit to an 88-year-old with mild forgetfulness is of concern?
a.The patient’s son uses a marked pillbox to set up the patient’s medications weekly.
b.The patient has lost 10 pounds (4.5 kg) during the last month.
c.The patient is cared for by a daughter during the day and stays with a son at night.
d.The patient tells the nurse that a close friend recently died.

Correct Answer: B

Rationale: A 10-pound weight loss may be an indication of elder neglect or depression and requires further assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an 88-year-old would have friends who have died.

Cognitive Level: Application Text Reference: pp. 71, 73-74

Nursing Process: Assessment NCLEX: Physiological Integrity

  1. A confused and agitated 76-year-old patient with a broken arm is brought to the emergency department by a family member. To determine whether elder abuse is the cause of the patient’s injury, the nurse should
a.have the family member stay in the waiting area while the patient is assessed.
b.ask the patient how the injury occurred and observe the family member’s reaction.
c.make a referral for a home assessment visit by the home health nurse.
d.notify an elder protective services agency about the possible abuse.

Correct Answer: A

Rationale: The patient should be assessed for clinical manifestations of other injuries, such as bruising and pressure ulcers and these should be documented and photographed. In addition, the patient should be interviewed alone because the patient will be unlikely to give accurate information if the abuser is present. If abuse is occurring, the patient should not be discharged home for a later assessment by a home health nurse. The nurse needs to collect and document physiologic data before notifying the elder protective services agency.

Cognitive Level: Application Text Reference: p. 74

Nursing Process: Assessment NCLEX: Physiological Integrity

  1. The family of an 85-year-old with chronic health problems and increasing weakness is considering placing the patient in a long-term care facility. Which action by the nurse will be most helpful in assisting the patient to make the transition?
a.Have the family select a LTC facility that is relatively new.
b.Obtain the patient’s input about the choice of LTC facility.
c.Ask that the patient be placed in a private room at the facility.
d.Explain the reasons for the need to live in LTC to the patient.

Correct Answer: B

Rationale: The stress of relocation is likely to be less when the patient has input into the choice of facility. The age of the long-term-care facility does not indicate a better fit for the patient or better quality of care. Although some patients may prefer a private room, others may adjust better when given a well-suited roommate. The patient should understand the reasons for the move but will make the best adjustment when involved with the choice to move and choice of facility.

Cognitive Level: Application Text Reference: p. 76

Nursing Process: Implementation NCLEX: Psychosocial Integrity

  1. Which information about a 77-year-old patient who is being assessed by the nurse is of most concern?
a.The patient takes two or three naps during the day and sleeps about 6 hours at night.
b.The patient uses five different medications for chronic heart and joint problems.
c.The patient says, “I don’t go on my daily walks since I had pneumonia 3 months ago.”
d.The patient organizes medications in a marked pillbox “so I don’t forget them.”

Correct Answer: C

Rationale: Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should develop a plan to prevent further deconditioning and restore function for the patient. A pattern of taking frequent naps during the day to compensate for shorter nighttime sleep periods is normal in older adults. On average, a 70-year-old takes seven different medications; the use of five medications is not unusual for a 78-year-old. The use of memory devices to assist with safe medication administration is recommended for older adults.

Cognitive Level: Application Text Reference: p. 80

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

  1. When admitting a 79-year-old patient who has urinary urgency and a possible urinary tract infection (UTI), the nurse should first
a.assess the patient’s orientation.
b.inspect for abdominal distension.
c.question the patient about hematuria.
d.invite the patient to use the bathroom.

Correct Answer: D

Rationale: Before beginning the assessment of an older patient with a UTI and urgency, the nurse should have the patient empty the bladder because bladder fullness or discomfort will distract from the patient’s ability to provide accurate information. The patient may seem disoriented if distracted by pain or urgency. The physical assessment data are obtained after the patient is as comfortable as possible.

Cognitive Level: Application Text Reference: p. 77

Nursing Process: Assessment NCLEX: Physiological Integrity

MULTIPLE RESPONSE

  1. Which nursing actions will the nurse take to assess for possible malnutrition in a 69-year-old patient? (Select all that apply.)
a.Review laboratory results.
b.Ask about transportation needs.
c.Determine food likes and dislikes.
d.Observe for depression.
e.Assess teeth and oral mucosa.
f.Question about salt use.

Correct Answer: A, B, D, E

Rationale: The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor protein intake or high-fat/cholesterol intake. Transportation impacts patients’ ability to shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor condition may decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated with malnutrition. Salt intake does not impact nutritional status.

Cognitive Level: Application Text Reference: p. 71

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

  1. Appropriate approaches used by the long-term care nurse to provide teaching to a 73-year-old who has just been diagnosed with diabetes include which of the following? (Select all that apply.)
a.Schedule a visit by another resident who is diabetic.
b.Demonstrate food choices using food photographs.
c.Avoid discussion of the patient’s favorite foods.
d.Remind the patient that a lot of damage has already occurred.
e.Encourage the patient’s family to participate in teaching sessions.
f.Ask the patient about past experiences with lifestyle changes.

Correct Answer: A, B, E, F

Rationale: Strategies to promote learning in older adults include peer teaching, visual aids, family participation, and relating new learning to past experiences. Discussion of the patient’s favorite foods is needed to determine how old favorites can be adapted to the new diet. Reminders about the damage already done will indicate that the changes are not worth the effort.

Cognitive Level: Application Text Reference: p. 79

Nursing Process: Implementation

NCLEX: Health Promotion and Maintenance

Lewis: Medical-Surgical Nursing, 7th Edition

Test Bank

Chapter 7: Community-Based Nursing and Home Care

MULTIPLE CHOICE

  1. A patient tells the nurse, “I have to be insured through a health maintenance organization (HMO) now. I don’t understand what a health maintenance organization is.” The best response by the nurse includes the information that
a.HMOs provide care in community settings, but hospitals are still used for acute care.
b.HMOs are designed to provide more cost-effective health care.
c.HMOs are better equipped to provide the care for aging patients.
d.HMOs are preferred by most consumers because the services offer more flexibility.

Correct Answer: B

Rationale: HMOs evolved to provide cost-effective health care. They provide for care in both community and acute settings. HMOs do cover many older adults, but they are not necessarily better equipped to provide care. HMOs have less flexibility than some other plans because they may offer less choice in providers, medications, etc.

Cognitive Level: Comprehension Text Reference: p. 86

Nursing Process: Implementation

NCLEX: Safe and Effective Care Environment

  1. A patient who belongs to an HMO is assigned a nurse as a case manager after being in an automobile accident. The actions of the nurse in this role are to
a.care for the patient during hospitalization for the injuries.
b.assist the patient with home care activities during recovery.
c.coordinate the services that the patient receives in the hospital and at home.
d.determine the types of medical care the patient needs for optimal rehabilitation.

Correct Answer: C

Rationale: The role of the case manager is to coordinate the patient’s care through multiple settings and levels of care to allow the maximal patient benefit at the least cost. The case manager does not provide direct care in either the acute or home setting. The case manager coordinates and advocates for care but does not determine what types of medical care are needed, which is done by the health care provider or other provider.

Cognitive Level: Comprehension Text Reference: p. 87

Nursing Process: Implementation

NCLEX: Safe and Effective Care Environment

  1. The ambulatory care nurse explains to an individual scheduled for an initial clinic appointment after joining an HMO that assigns an RN case manager to every patient in the HMO. The nurse will further explain that
a.the case manager will coordinate the care given to the patient by various members of the health care team.
b.one nurse will be responsible for planning all the interventions needed for the patient in acute and community settings.
c.the ambulatory care nurse is responsible for collaboration with other health care disciplines to plan all future patient care.
d.a health care provider will manage the patient’s care with the assistance of nursing and other professional staff members.

Correct Answer: A

Rationale: When the managed care approach is used, the patient’s care is coordinated across multiple settings and various disciplines. Plans of care are developed by the nurses in the acute and community settings based on patient assessments in those settings. Although the ambulatory care nurse does collaborate with other health care disciplines, this nurse will not plan all future care. The health care provider management of the patient’s medical care does not describe case management, which refers to various services needed by the patient.

Cognitive Level: Comprehension Text Reference: p. 87

Nursing Process: Implementation

NCLEX: Safe and Effective Care Environment

  1. A 78-year-old patient hospitalized for surgical repair of a fractured hip has recovered from the surgery but continues to have a nursing diagnosis of impaired physical mobility related to decreased muscle strength. The nurse will anticipate transferring the patient to
a.an acute care setting.
b.a transitional care setting.
c.a residential care facility.
d.an intermediate care facility.

Correct Answer: B

Rationale: Transitional care settings are appropriate for patients who need continued rehabilitation before discharge to home or to long-term-care settings. The patient is no longer in need of the more continuous assessment and care given in acute care settings. There is no indication that the patient will need the permanent and ongoing medical and nursing services available in intermediate care. The patient is not yet independent enough to transfer to a residential care facility.

Cognitive Level: Application Text Reference: pp. 87-88

Nursing Process: Planning

NCLEX: Safe and Effective Care Environment

  1. Which of these nursing activities is appropriate for the home care RN who is caring for a newly diagnosed diabetic patient to delegate to a home health aide?
a.Assisting the patient to choose an appropriate diet.
b.Checking the patient’s feet for signs of breakdown.
c.Taking the patient’s vital signs before a daily bath.
d.Teaching the patient how to monitor blood glucose.

Correct Answer: C

Rationale: Taking vital signs is included in home health-aide education and scope of practice. Assessment of the patient and instructing the patient in new skills, such as diet and blood glucose monitoring, are complex skills that are included in RN education and scope of practice.

Cognitive Level: Application Text Reference: pp. 90-91

Nursing Process: Implementation

NCLEX: Safe and Effective Care Environment

  1. In describing home care services to a patient requiring extended care, the nurse tells the patient that
a.home care services are limited to visits by registered nurses or home health aides.
b.in order for Medicare or insurance to cover the expenses of home care, the patient must be confined to bed.
c.the patient’s family will be included in planning and teaching about the patient’s care.
d.technologically complex therapies, such as mechanical ventilators, are better managed in the hospital.

Correct Answer: C

Rationale: Family members who are providing care are included in teaching about the patient’s care and treatments. Other disciplines also provide appropriate home health services. The patient must be homebound, but not bed bound, to receive reimbursement for home care services. High-tech services are increasingly accomplished in the home setting, where the patient is more comfortable and the risks for complications such as infection are less.

Cognitive Level: Application Text Reference: pp. 89, 91

Nursing Process: Implementation

NCLEX: Safe and Effective Care Environment

  1. Which of these patients being discharged by the acute care nurse meets the requirements for Medicare reimbursement for home health services?
a.A 65-year-old patient with multiple sclerosis and severe weakness who requires sacral dressing changes
b.A 68-year-old diabetic patient who is unable to drive and needs teaching about a diabetic diet and lifestyle
c.A 70-year-old who receives daily intravenous antibiotics for an infected leg wound
d.A 71-year-old who needs weekly blood sampling for monitoring of prothrombin times

Correct Answer: A

Rationale: The patient with severe weakness meets the standard because it would require considerable effort to leave the home for the complex sacral dressing changes. The diabetic patient is able obtain transportation to an ambulatory setting for diabetic teaching. The patient with the leg wound is able to receive daily antibiotics in an outpatient setting. Weekly blood samples can be obtained in a laboratory and do not require home health services.

Cognitive Level: Application Text Reference: p. 91

Nursing Process: Assessment

NCLEX: Safe and Effective Care Environment

  1. The home health nurse visits a diabetic patient who has an infected heel wound to perform daily dressing changes and wound assessment. The nursing diagnosis of impaired tissue integrity is developed for the patient. To evaluate the patient outcome, the nurse will collect data about
a.the patient’s daily capillary blood glucose level.
b.the presence or absence of complications of diabetes.
c.the wound appearance and patient temperature.
d.the patient’s appraisal of the nursing services provided.

Correct Answer: C

Rationale: Because the patient’s nursing diagnosis is impaired tissue integrity, the evaluation of outcomes is based on wound appearance and patient temperature. The blood glucose, the presence of complications of diabetes, and the patient’s evaluation of nursing services are important data to collect, but they are not helpful in evaluating outcomes for this nursing diagnosis.

Cognitive Level: Application Text Reference: p. 90

Nursing Process: Evaluation NCLEX: Physiological Integrity

  1. When making an initial home visit, the most appropriate approach by the nurse is to
a.tell the patient and family all of the planned interventions.
b.ask the patient and family what their expectations are.
c.discuss the importance of following through with health care provider orders.
d.instruct the family members that they will need to participate in care.

Correct Answer: B

Rationale: The nurse is a visitor in the home setting, and the most effective initial approach is to determine the expectations of the patient and family for the home health experience. The other approaches indicate that the nurse or health care team is in charge of care, which is not the case in this setting.

Cognitive Level: Application Text Reference: pp. 90-91

Nursing Process: Implementation NCLEX: Psychosocial Integrity

  1. Which of these patients should the nurse refer for Medicare-reimbursed home health services?
a.A 67-year-old who requires assistance with shopping, housework, and cooking
b.A 71-year-old with dementia who needs 24-hour care to prevent injury
c.A 79-year-old who needs to have medications placed in a marked pillbox weekly
d.An 82-year-old whose family has asked for respite care for a few days a month

Correct Answer: C

Rationale: Medicare will reimburse for intermediate skilled nursing care, such as setting up medications once weekly. Services such as shopping, housework, and cooking are not skilled nursing services and are not reimbursed by Medicare or most insurers. Chronic care that is needed 24 hours daily does not meet the Medicare requirements. Respite care is not skilled nursing and does not meet the requirement for home health services.

Cognitive Level: Application Text Reference: p. 89

Nursing Process: Implementation

NCLEX: Safe and Effective Care Environment

MULTIPLE RESPONSE

  1. When practicing as a home health care nurse, the RN (Select all that apply.)
a.plans for the health needs of community groups.
b.provides direct care for an individual patient.
c.participates in group screening for common health problems such as hypertension.
d.teaches patients’ family members how to provide care such as giving medications.
e.administers chemotherapy and antibiotics through long-term intravenous catheters.
f.instructs groups about special health care needs such as contraception or baby care.

Correct Answer: B, D, E

Rationale: The home health care nurse provides community-based nursing to an individual patient and/or family. Care for community groups or populations is considered public health nursing or community health nursing.

Cognitive Level: Comprehension Text Reference: pp. 88-90

Nursing Process: Implementation

NCLEX: Safe and Effective Care Environment

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