Question 1

Which of the following best describes the primary aim of care coordination in interprofessional collaborative practice?

Accepted Answer

To link patients with resources in the community, improve information exchange, and reduce fragmentation and duplication of services

Question 2

A nurse is preparing to transfer a patient from the hospital to a rehabilitation facility. Which communication method should the nurse use to ensure a comprehensive handoff, and what is a key component of this method?

Accepted Answer

ISBARQ; including an opportunity for questions and answers at the end of the handoff

Question 3

Which of the following is NOT considered a direct health need identified in the Johns Hopkins Hospital Community Health Needs Assessment?

Accepted Answer

Housing/homelessness

Question 4

A patient with a newly diagnosed chronic disease is being discharged home. According to the criteria for formal discharge planning and referrals, which of the following is the most appropriate action?

Accepted Answer

Initiate a formal discharge plan and consider referrals to community resources

Question 5

Which of the following best illustrates the role of a nurse navigator in care coordination?

Accepted Answer

Identifying and removing barriers to treatment and serving as the central point of contact for patient care

Question 6

A patient is admitted to a same-day surgery clinic. According to best practices, when should screening tests and patient teaching occur?

Accepted Answer

Prior to admission to the clinic

Question 7

Which of the following is a core competency for interprofessional collaborative practice?

Accepted Answer

Effective team structure and communication among health care providers

Question 8

A patient is being discharged from the hospital. According to discharge planning guidelines, which step should occur FIRST?

Accepted Answer

Assess and identify the patient’s health care needs

Question 9

Which of the following populations is considered vulnerable and may require additional care coordination?

Accepted Answer

People experiencing poverty in rural and urban areas

Question 10

A patient decides to leave the hospital against medical advice (AMA). Which of the following is a required legal step in this process?

Accepted Answer

The patient must sign a release form, and the signature must be witnessed

Question 11

Which of the following is an example of a community-based health care service?

Accepted Answer

Managing chronic illness and promoting self-care in a patient’s home

Question 12

A nurse is coordinating care for a patient with multiple chronic conditions who is uninsured. Which Healthy People 2030 leading health indicator is most relevant to this scenario?

Accepted Answer

Uninsured or underinsured status

Question 13

Which of the following is a key responsibility of the community-based nurse as a patient advocate?

Accepted Answer

Ensuring the patient’s preferences and needs are represented in care planning

Question 14

A patient is being admitted to the hospital. Which of the following pieces of information is NOT typically obtained on the admission sheet?

Accepted Answer

Patient’s favorite food

Question 15

Which of the following best describes telehealth?

Accepted Answer

Using electronic information and telecommunication technologies to provide care remotely

Question 16

A nurse is planning discharge for a patient with limited family support and a complex home health care regimen. Which of the following is the most appropriate action?

Accepted Answer

Initiate a formal discharge plan and consider referrals to home health care services

Question 17

Which of the following is a critical step in infection prevention for home health care services?

Accepted Answer

Educating patients and caregivers on proper hand hygiene techniques

Question 18

A nurse is using the ISBARQ method for patient handoff. Which of the following correctly matches the 'A' in ISBARQ?

Accepted Answer

Assessment

Question 19

Which of the following scenarios best demonstrates continuity of care?

Accepted Answer

A nurse ensures a smooth transition for a patient from acute care to home health care, using ISBARQ for communication

Question 20

A patient with a terminal illness is being discharged home. Which of the following services would be most appropriate to recommend?

Accepted Answer

Hospice services

Community-Based Health Care, Care Coordination, and Interprofessional Practice

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