Medical-Surgical Nursing
8th Edition
Author(s)Adrianne Dill Linton;
Mary Ann Matteson
Print ISBN: 9780323826716
TEST BANK
1) MCQ
Clinical Scenario
,A patient is discharged home after treatment for heart failure.
The home health nurse makes the first visit the next day. The
patient says, “I am not sure where to start. My pillbox is still in
the kitchen, and I have not weighed myself since I got home.”
Question Stem
What is the nurse’s priority action during this first visit?
Answer Options
A. Document that the patient is nonadherent with self-
management
B. Assess the home environment and the patient’s ability to
manage medications and daily weights
C. Teach the patient the entire heart failure diet in one session
D. Call the provider to request readmission
Correct Answer
B
Detailed Rationale
The priority in home health is to assess the home environment,
medication setup, and self-management ability before
planning teaching or escalation. The nurse needs to identify
barriers such as vision, cognition, health literacy, organization,
and safety hazards.
Incorrect Option Analysis
, A is premature. The nurse has not yet assessed why the
patient has not started self-care.
C is important but not first. Teaching should be based on
assessment and patient readiness.
D is unnecessary at this point unless the assessment
reveals instability or inability to remain safely at home.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues, Analyze Cues
Difficulty Level
Moderate
Bloom’s Cognitive Level
Apply
NCLEX Client Needs Category
Management of Care
Key Learning Objective
Identify the nurse’s first priority in home health assessment
after hospital discharge.
, 2) SATA
Clinical Scenario
A patient with left-sided weakness after a stroke is being
evaluated for transfer to an inpatient rehabilitation facility.
Question Stem
Which findings support that inpatient rehabilitation is an
appropriate setting for this patient? Select all that apply.
Answer Options
A. The patient is medically stable
B. The patient can participate in intensive therapy sessions
C. The patient requires 24-hour ventilator support
D. The patient needs PT, OT, and speech therapy
E. The patient wants to regain independence in dressing and
feeding
F. The patient is confused, combative, and unable to follow any
commands
Correct Answers
A, B, D, E
Detailed Rationale
Inpatient rehabilitation is appropriate when the patient is
medically stable and can tolerate intensive, interdisciplinary
8th Edition
Author(s)Adrianne Dill Linton;
Mary Ann Matteson
Print ISBN: 9780323826716
TEST BANK
1) MCQ
Clinical Scenario
,A patient is discharged home after treatment for heart failure.
The home health nurse makes the first visit the next day. The
patient says, “I am not sure where to start. My pillbox is still in
the kitchen, and I have not weighed myself since I got home.”
Question Stem
What is the nurse’s priority action during this first visit?
Answer Options
A. Document that the patient is nonadherent with self-
management
B. Assess the home environment and the patient’s ability to
manage medications and daily weights
C. Teach the patient the entire heart failure diet in one session
D. Call the provider to request readmission
Correct Answer
B
Detailed Rationale
The priority in home health is to assess the home environment,
medication setup, and self-management ability before
planning teaching or escalation. The nurse needs to identify
barriers such as vision, cognition, health literacy, organization,
and safety hazards.
Incorrect Option Analysis
, A is premature. The nurse has not yet assessed why the
patient has not started self-care.
C is important but not first. Teaching should be based on
assessment and patient readiness.
D is unnecessary at this point unless the assessment
reveals instability or inability to remain safely at home.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues, Analyze Cues
Difficulty Level
Moderate
Bloom’s Cognitive Level
Apply
NCLEX Client Needs Category
Management of Care
Key Learning Objective
Identify the nurse’s first priority in home health assessment
after hospital discharge.
, 2) SATA
Clinical Scenario
A patient with left-sided weakness after a stroke is being
evaluated for transfer to an inpatient rehabilitation facility.
Question Stem
Which findings support that inpatient rehabilitation is an
appropriate setting for this patient? Select all that apply.
Answer Options
A. The patient is medically stable
B. The patient can participate in intensive therapy sessions
C. The patient requires 24-hour ventilator support
D. The patient needs PT, OT, and speech therapy
E. The patient wants to regain independence in dressing and
feeding
F. The patient is confused, combative, and unable to follow any
commands
Correct Answers
A, B, D, E
Detailed Rationale
Inpatient rehabilitation is appropriate when the patient is
medically stable and can tolerate intensive, interdisciplinary
