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An HMO client obtained a second opinion regarding a diagnosis of colon cancer. There was no authorization obtained for this second opinion from the client or primary care provider. What is the consequence of this action?
- A. The client will be responsible for the entire bill for the second opinion.
- B. The client will still receive full coverage.
- C. The client will be dropped from the HMO for breaking the rules.
- D. The client will be fined by the HMO for not using the authorization process.
Correct Answer: A
Rationale: Members of an HMO must receive authorization for secondary care, such as second opinions from specialists or diagnostic testing. If members obtain unauthorized care, they are responsible for the entire bill. In this way, HMOs serve as gatekeepers for healthcare services. The member will not be fined or dropped from the program but will not receive coverage for the service rendered from the second opinion.
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The nurse informs the administrative assistant that a client is expected to come in for lab work. The administrative assistant asks why the nurse refers to the individual as a client. What is the best response by the nurse?
- A. We should refer to everyone as a client. They pay for our service.'
- B. That's how the physician wants us to refer to them.'
- C. Using the term client implies that they are an active partner in nursing care.'
- D. Using the term client is more respectful that using the term patient.'
Correct Answer: C
Rationale: A client is an active partner in nursing care, and the person receiving healthcare services should no longer play a passive, ill role. The use of the term client reflects the attitude of personal responsibility for health. Though clients may be paying for these services, some physicians may request their staff members to use this terminology, and some people may consider it to be a more respectful term than 'patient', these are not the primary reasons to refer to the individual as a client.
The client is referred from the physician to a cardiologist for a cardiac catheterization to determine if the client has coronary artery disease. What type of care does the nurse understand that this is?
- A. Primary care
- B. Secondary care
- C. Tertiary care
- D. Acute care
Correct Answer: B
Rationale: Secondary care includes referrals to facilities for additional testing such as cardiac catheterization, consultation, and diagnosis as well as emergency and acute care interventions. This client falls into this category due to the referral to the cardiologist for the cardiac catheterization. The client does not fall into the acute care category. Primary care would include being seen by the client's primary physician. Tertiary care focuses more on complex medical and surgical interventions, cancer care, rehabilitative services, long-term care such as burn care, and palliative and hospice care.
What method for financing healthcare is based on the ability to keep clients healthy and out of the hospital through periodic screening, health education, and preventive services?
- A. Managed care
- B. Preferred provider organization
- C. Health maintenance organization
- D. Point-of-service organization
Correct Answer: C
Rationale: Health maintenance organizations strive to keep their costs low and members out of the hospital through periodic screenings, health education, and preventive services. Managed care organizations are insurers who carefully plan and closely supervise the distribution of healthcare services. Preferred provider organizations are a community network of providers who are willing to discount their fees for service in exchange for a steady stream of referral customers. Point-of-service organizations involve a network of providers; clients select a primary care physician within the group who then serves as the gatekeeper for other healthcare services.
Managed care organizations are insurers that carefully plan and closely supervise the distribution of healthcare services. What is one of the goals of managed care?
- A. Preventing illness through screening and promotion of health activities
- B. Improving training of healthcare professionals
- C. Eliminating health disparities between segments of the population
- D. Providing hospice or home hospice care
Correct Answer: A
Rationale: Preventing illness through screening and promotion of health activities is one of the goals of managed care. Improved training of healthcare professionals is the priority for international health and not the goal of managed care. Eliminating health disparities between the segments of population is a goal of Healthy People 2030. Providing hospice or home hospice care is only for terminally ill clients.
The nurse has been asked to assist in gathering data regarding the incidence of falls in the hospital as part of a project that is geared toward identifying avoidable contributing factors and their effects. What type of quality indicators (QI) is this considered?
- A. Prevention QI
- B. Inpatient QI
- C. Client safety QI
- D. Pediatric QI
Correct Answer: C
Rationale: Client safety QIs reflect quality of care within hospitals but focus on potentially avoidable complications and adverse effects. Prevention QIs identify hospital admissions that could be avoided through high-quality outpatient care. Inpatient QIs reflect quality of care inside hospitals, including inpatient mortality for medical conditions and surgical events. The question does not indicate that client age is considered when gathering data, so Pediatric QIs would not be relevant here.