The Nurse in Home Health and Hospice

1. Which of the following statements best describes the most essential difference between home health care and acute client care?

a.
Acute client care is individualized for the client and family.
b.
Home health care is provided in the client’s environment.
c.
Reimbursement for home health care varies from that of care provided in institutions.
d.
The focus of acute client care is on community health.

ANS: B

Home health differs from other areas of health care in that health care providers practice in the client’s environment. All nurses give individualized care to clients.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 550

2. A nurse has just received word that Medicaid will reimburse for care provided to a homeless man with schizophrenia who is afraid to come to the clinic to receive health care. Which of the following best describes this type of nursing?

a.
Community-oriented nursing
b.
Home health nursing
c.
Hospice nursing
d.
Private duty nursing

ANS: B

Home health nursing is provided in the client’s environment, regardless of where that may be. “Home” may be a house, apartment, trailer, boarding house, shelter, car, makeshift shelter under a bridge, or cardboard box.

DIF: Cognitive Level: Apply (Application) REF: p. 550

3. A hospital nurse wants to know why home health nurses often take more time with assessment than nurses do in the hospital. Which of the following is the best explanation for this?

a.
Home care assessment includes not only the client but the supplies and equipment the family may have available for use.
b.
The home environment is less organized and equipped for the nurse’s use.
c.
Family members must also be assessed for possible problems that could interfere with the primary client’s recovery.
d.
To be effective, the home health nurse must earn the family’s trust and work in partnership with them.

ANS: D

Although all the responses contain some truth, the primary reason that assessment may take longer for the home health nurse is because when working in a client’s home, the nurse is a guest. To be effective, the nurse must earn the trust of the family and establish a partnership with client and family.

DIF: Cognitive Level: Apply (Application) REF: p. 551

4. Which of the following events led to the emphasis on home care nurses caring for acutely ill clients and the increased demands for extensive documentation?

a.
Advances in medical technology and pharmacology
b.
Increased number of lawsuits for substandard care
c.
Introduction of Medicare
d.
Social Security Act of the 1930s

ANS: C

The combination of preventive services and illness care followed the introduction of Medicare in 1966. The Medicare program emphasized care for more acutely ill people rather than illness prevention and health promotion. The 1997 federal Balanced Budget Act, which implemented the prospective payment system in home care, increased pressure to care for clients with acute illnesses that were likely to improve.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 551

5. In the agency, one of the nurses spent all available time visiting a group of persons with mental health problems who were trying to remain functional in the community. Which of the following types of assignments did the nurse most likely have?

a.
Home-based primary care
b.
Population-focused home care
c.
Proprietary home care
d.
Transitional care

ANS: B

Population-focused home care is directed toward the needs of specific groups of people, including those with high-risk health needs such as mental health problems, cardiovascular disease, or diabetes; families with infants or young children; and older adults. Such care commonly includes structured regular visits with assessment protocols, focused health education, counseling, and health-related support and coaching.

DIF: Cognitive Level: Apply (Application) REF: p. 551

6. A new client has just been released from the hospital after intensive treatment for multiple injuries following a motorcycle accident. Which of the following types of care will he most likely receive?

a.
Home-based primary care
b.
Population-focused home care
c.
Proprietary home care
d.
Transitional care

ANS: D

Transitional care programs in the home are designed for populations who have complex or high-risk health problems and are making a transition from one level of care to another. Assessment, planning, teaching, making referrals, and following up on referrals foster independence and self-care. Besides intensive teaching about self-care, telephone calls help ensure that the client understands and is able to implement instruction.

DIF: Cognitive Level: Apply (Application) REF: p. 552

7. Which of the following types of home health agencies emphasizes health promotion and illness prevention?

a.
Combination agencies
b.
Hospital-based agencies
c.
Official agencies
d.
Proprietary agencies

ANS: C

Official or public agencies include those agencies operated by the state, county, city, or other local government units, such as health departments. Nurses employed in these settings provide well-child clinics, immunizations, health education programs, and home visits for preventive health care. Consequently, they include a focus on health promotion and illness prevention as well as giving direct care.

DIF: Cognitive Level: Remember (Knowledge) REF: pp. 552-553

8. Which of the following is a potential advantage of hospital-based home health agencies over other types of home care agencies?

a.
Administration and management benefits are gained from the expertise of two boards of experts.
b.
Continuity of care is enhanced.
c.
Health promotion and illness prevention concerns take precedence over acute care and rehabilitation.
d.
They are eligible for tax exemptions through affiliated agencies.

ANS: B

Hospital-based agencies emerged in response to the recognized need for continuity of care from the acute care setting.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 553

9. Which of the following is the primary focus of hospice care?

a.
Curing or controlling the client’s chronic disease
b.
Decreasing the waste of acute care (hospital) resources
c.
Providing palliative care to maintain comfort until death
d.
Teaching the client and family how to care for themselves

ANS: C

The primary goal of hospice care is to help maintain the client’s dignity and comfort. Alleviating pain; encouraging the client, family, and friends to communicate with each other about essential sensitive issues; and coordinating care to ensure a comfortable, peaceful death all contribute to palliative care.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 553

10. Which of the following best describes why it is more challenging for most nurses to meet the needs of a dying child and his or her family than to meet the needs of a dying adult?

a.
Children don’t understand what it means to die.
b.
A child’s death is harder for anyone to accept.
c.
Society does not expect death to occur in children.
d.
Families are not prepared to deal with death.

ANS: C

It is true that families are rarely prepared to deal with death. It is also true that children have only a limited understanding of dying. However, the needs of the dying child and family are unique because society does not expect death to occur to the young or to have the child die before the parent.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 554

11. When meeting with a client and family, the home health nurse says, “We have discussed your health problems and limitations. Now tell me what level of health and function you hope to achieve.” In which of the following phases of the nursing process is the nurse engaging?

a.
Assessment
b.
Diagnosis
c.
Outcome identification
d.
Planning

ANS: C

When discussing health problems and limitations, the nurse was gathering a history as part of the assessment phase. This allowed formulation of a nursing diagnosis. By steering the conversation toward goals, the nurse is now able to work with the client to mutually identify outcomes.

DIF: Cognitive Level: Analyze (Analysis) REF: pp. 554-555

12. A home health nurse asks a client with arthritis to attend a demonstration in which an assistive device is used to put on shoes. Which phase of the nursing process is the nurse’s current focus?

a.
Outcome identification
b.
Planning
c.
Implementation
d.
Evaluation

ANS: C

Implementation is the phase in which the home health nurse implements the interventions identified in the plan of care. If the client is able to use the device, the process can progress to evaluation, in which the nurse will assess the usefulness of the device when incorporated into the client’s activities of daily living.

DIF: Cognitive Level: Analyze (Analysis) REF: pp. 554-555

13. A home health nurse is caring for a client who has right-sided paresis secondary to a stroke. Which of the following would be the best approach for the nurse to take?

a.
Arrange for private duty nurses to assist the client with daily needs.
b.
Assist the client with activities of daily living.
c.
Teach the client to participate in self-care activities.
d.
Teach the family how to care for the client.

ANS: C

Because home health care is often intermittent, and because a reliance on others is not always possible over the long term, a primary objective for the nurse is to facilitate self-care so that clients may remain in their home. This allows clients to have some control over their life and can help prevent hopelessness and a loss of self-esteem. Although assistance may be needed, such assistance should come after helping clients to help themselves.

DIF: Cognitive Level: Apply (Application) REF: p. 556

14. Which of the following do community-based nurses typically use to organize, sort, and document pertinent client data?

a.
NANDA
b.
NIC NOC
c.
Nursing Diagnosis Taxonomy
d.
The Omaha System

ANS: D

Although all four are recognized nursing taxonomies, in community health, especially home nursing, the Omaha System is typically used. This system was developed by a visiting nurses association in Omaha and based on home nursing documentation needs. The Omaha System is most relevant to home health nursing and is most typically used by home health nurses.

DIF: Cognitive Level: Understand (Comprehension) REF: pp. 556-557

15. Which of the following should be the minimum requirement for a nurse to be prepared for home health nursing?

a.
An RN license and a baccalaureate degree in a health-related field
b.
A baccalaureate degree in nursing and RN licensure
c.
An associate’s degree in nursing and RN licensure
d.
Eligibility for certification as a home health nurse

ANS: B

A baccalaureate degree in nursing should be the minimum requirement for entry into professional practice in any community health setting.

DIF: Cognitive Level: Remember (Knowledge) REF: p. 557

16. A nurse orienting to the home health role states, “I don’t understand why we have to collaborate with so many other disciplines; this conflicts with the concept of nurses providing all direct care to the client in the home?” Which of the following would be the best response?

a.
“The nurse still provides direct care for the client; however, interdisciplinary collaboration is necessary to prevent fragmentation of care.”
b.
“Direct nursing care is a concept applied to care in tertiary facilities, such as hospitals, where materials are centrally located in one facility. In home health, this is not possible.”
c.
“Even though home health nursing does not provide as much direct care as other nursing specialties in the community, each discipline contributes to client needs from its special knowledge base.”
d.
“Yes, it does create conflict, but Medicare mandates interdisciplinary collaboration.”

ANS: A

The responsibilities and functions of other health professions in home care are dictated by Medicare regulations, professional organizations, and state licensing boards. Many of these services can be provided on a consulting basis. The plan of care should be implemented and reinforced by all involved disciplines. Therefore, interdisciplinary collaboration is required in the home health setting. Such collaboration does not conflict with the concept of providing direct care services. Direct care refers to the actual physical aspects of nursing care—anything requiring physical contact and face-to-face interactions. In home care, direct care activities include performing a physical assessment on the client, changing a dressing on a wound, giving medication by injection, inserting an indwelling catheter, or providing intravenous therapy. Direct care also involves teaching clients and family caregivers how to perform a certain procedure or task.

DIF: Cognitive Level: Apply (Application) REF: pp. 555, 558

17. A nurse completes a self-assessment of performance as part of the home health nurse’s annual evaluation. Which of the following terms best describes this activity?

a.
Collaboration
b.
Quality of care
c.
Performance appraisal
d.
Resource utilization

ANS: C

As part of a performance appraisal, the home health nurse evaluates his or her own nursing practice in relation to professional practice standards, scientific evidence, and relevant statutes, rules, and regulations.

DIF: Cognitive Level: Apply (Application) REF: pp. 558-559

18. Which of the following best describes when the home health nurse must document required Outcome and Assessment Information Set (OASIS-B1) data?

a.
Before any episode of hospitalization
b.
After each home health visit
c.
For all incidences of error or mistake in care
d.
On first admission to home health care

ANS: D

OASIS-B1 data are measured and reported to CMS (1) on admission to home health care, (2) after an episode of hospitalization, (3) at the time of recertification, and (4) on discharge from care or death at home. Data are submitted by each agency to a national databank, and agencies receive both results and comparisons with similar agencies to determine areas needing improvement. The data reported from OASIS determine the payment received by the home health agency for the client’s total episode of care.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 559

19. The board of directors is examining various submitted reports concerning its home health agency. Which of the following reports represents an example of benchmarking?

a.
A report by the administrator regarding how the home health agency’s performance compares with that of other local and national home health agencies
b.
A report by the chief financial officer regarding a cost-benefit analysis related to technological advances
c.
A report by the chief nursing officer regarding client outcomes
d.
A report by the medical director regarding implementation of evidence-based practice into standards of care

ANS: A

Performance improvement programs are based on measurable data, including benchmarking, which means comparing oneself with national standards and guidelines and with other agencies.

DIF: Cognitive Level: Apply (Application) REF: p. 559

20. Which of the following comments was most likely stated by a home health nurse?

a.
“Every time I see a client, it costs $80.”
b.
“Health care costs are killing our economy.”
c.
“I can’t believe how much clients are charged for things.”
d.
“Medicaid costs are such a large portion of our state’s budget.”

ANS: A

Nurses in many settings are not directly exposed to the financial aspects of health care, although as citizens they should be aware of the overall effects of high health care costs. In home health, nurses must be cost-conscious so that they can accurately explain to clients what Medicare will or will not cover and discuss other financial concerns. In addition, home care nurses must be knowledgeable about which medical supplies are covered.

DIF: Cognitive Level: Apply (Application) REF: p. 560

21. Which of the following best describes one of the outcomes of the incentives and pressures for cost control and improved health outcomes?

a.
Expansion in alternative health care agencies
b.
Improvements in client teaching materials
c.
Public pressure to improve health professionals’ education
d.
Development and increased use of telehealth technology

ANS: D

The incentives and pressures for cost control and improved health outcomes have increased the development and use of telehealth technology in home care. Simultaneously, technologies have been simplified and their reliability increased, facilitating their safe use in the home.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 561

22. Which of the following is a primary requirement for a client to be eligible for home health nursing and Medicare reimbursement of services?

a.
Must be homebound
b.
Must be living in a medically underserved area
c.
Must be indigent
d.
Must be insured or eligible for Medicare or Medicaid

ANS: A

To receive home health services, clients must be homebound. Although home health care is less expensive than hospitalization, it remains much more costly than a traditional visit to a clinic; therefore, those who are not homebound would be expected to receive care at a clinic.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 560

23. Which of the following clients over 65 years of age meets the criteria for Medicare reimbursement for home health nursing?

a.
The client who needs assistance with bathing and meal preparation
b.
The client who needs assistance with house cleaning and meal preparation
c.
The client who needs sitter services because she wanders from home and becomes lost
d.
The client whose family members need to learn how to care for his wound

ANS: D

Because the nursing service must be considered “skilled,” custodial services alone (e.g., sitter services and assistance with ADLs) are not sufficient cause for Medicare reimbursement.

DIF: Cognitive Level: Apply (Application) REF: p. 560

24. Which of the following best explains why the home health nurse would essentially repeat the same information given to the client by the nurse in the hospital?

a.
Clients find it difficult to learn in the midst of the stress of the acute care setting and often don’t remember what the hospital nurse taught.
b.
Hearing something from a different person, using different words and examples, can help ensure that learning is retained.
c.
Home health nurses often don’t know what hospital-based nurses have already taught.
d.
Learning depends on receiving information more than once.

ANS: A

Although all of the responses are potentially true, the bottom line is that clients may find it difficult to learn while they are hospitalized. Consequently, home care nurses should communicate clearly with discharge planners about the therapeutic plan and medication regimens, as well as what clients have been taught about self-care and symptoms that should be reported to the physician. The nurse should share this same information again, unless the client clearly demonstrates having the knowledge and skills being reviewed.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 552

25. A family member asks a home health nurse to explain the concept of hospice care. Which of the following would the nurse need to include as the fundamental underlying philosophy of hospice?

a.
Enabling the client to die at home
b.
Ensuring that the client’s living will is upheld
c.
Placing experts in the position of power of attorney
d.
Providing comfort measures before death

ANS: D

The hospice philosophy of care means providing comfort measures to an individual before death. Death may occur in the individual’s home, in a hospital setting, or in an uncontrolled setting such as the community.

DIF: Cognitive Level: Apply (Application) REF: p. 554

26. Which of the following practices in the home is most crucial?

a.
Using good handwashing procedures
b.
Obtaining a puncture-resistant container for family to use for needles
c.
Putting all contaminated material directly into a trash bag
d.
Washing all surfaces with disinfectant

ANS: A

Universal precautions mean that all blood and body fluids are treated as potentially infectious, especially because many infections are subclinical. The nurse would use extreme care to prevent injuries when handling needles, scalpels, and razors and discard needles and syringes in puncture-resistant containers; use protective coverings if contact with blood and body fluids is expected; put materials contaminated with body fluids in double polyethylene garbage bags; and tell the family to be sure to use detergent in warm water to clean kitchen counters, dishes, and laundry and household disinfectant when cleaning the bathrooms. However, the single most important practice in preventing infections is careful hand washing before and after client care, touching food, or using the bathroom.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 555

MULTIPLE RESPONSE

1. Which of the following aspects of a home health agency would most likely be examined during the accreditation process? (Select all that apply.)

a.
Cost of each service rendered
b.
Credentials of each employee
c.
Organizational structure
d.
Outcomes of care

ANS: C, D

Both The Joint Commission (TJC) and the Community Health Accreditation Program (CHAP) of the National League for Nursing (NLN) look at the organizational structure through which care is delivered, the process of care through home visits, and the outcomes of client care, focusing on improved health status. Performance improvement must be ongoing in the agency. It is assumed the credentials of each employee were confirmed before employment.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 559

2. A family is concerned about the medical bills of their father, age 63, who is unemployed and has almost no savings. Which of the following statements by the nurse accurately explain how Medicaid and Medicare would work in this family’s situation? (Select all that apply.)

a.
“All your father’s medical bills will be paid by whichever program is appropriate.”
b.
“Choose any physician and just show them your Medicare or Medicaid card.”
c.
“Your father must be homebound to qualify for Medicare assistance but less so for Medicaid.”
d.
“Medicare is a federally funded program, but Medicaid is administered by your state.”

ANS: C, D

Many physicians will not accept a client on Medicare or Medicaid because of the low reimbursement rates. A deduction from Social Security is made for Medicare premiums, and clients are still responsible for deductibles and copays, so it is misleading to tell the family that all their father’s medical bills will be paid. Medicare, for those age 65 and over or disabled, is a federal insurance program administered by the Social Security Administration, whereas Medicaid, based on a client’s lack of financial resources, is a federal and state assistance program administered by the state. Medicare will only pay for home health care by skilled professionals while the client is homebound, whereas Medicaid does not necessarily require homebound status and may reimburse for home health aides and other nonskilled supportive services.

DIF: Cognitive Level: Apply (Application) REF: p. 560