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What does the nurse understand is the focus of healthcare when a client receives services from a health maintenance organization (HMO)?
- A. Avoiding coverage for needed services
- B. Health promotion and maintenance
- C. To offer discounted services to all patients
- D. High-quality service and contain cost
Correct Answer: B
Rationale: If the HMO does not require much high-cost care, providers make money; if members use many high-cost resources, providers lose money. This method of financing provides the strongest incentives for limiting use of expensive services and focusing healthcare on health maintenance and promotion. If services such as diagnostic testing are required, the HMO will cover this and not avoid payment. Services are not discounted for patients that are nonmembers or members. The goals of a physician hospital organization (PHO) are to maintain high-quality service and contain costs while fostering group contracts, collaboration, and capitation.
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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.
A 17-year-old client is having protected sex one to two times a week in a monogamous relationship. What is the client participating in?
- A. Health promotion
- B. Health maintenance
- C. Illness prevention
- D. Wellness
Correct Answer: B
Rationale: Protecting one's current level of health by practicing safe sex to prevent illness is an example of a health maintenance activity. Health promotion strategies are used to enhance health, such as eating a diet high in fiber. Illness prevention includes identifying risk factors such as hypertension. Wellness is the balance of total well-being.
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.
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 is leading a cardiac rehabilitation support group. How can the nurse best demonstrate meeting the client's needs holistically?
- A. Lead an exercise, show a video about healthy lifestyle changes, and invite a spiritual leader to talk with the group.
- B. Have the clients share various healthy low-cholesterol recipes and participate in a cooking class.
- C. Have the clients discuss ways to relieve stress and practice stress reduction.
- D. Demonstrate low-impact aerobic exercise to the group and bring in a lecturer on Tai Chi.
Correct Answer: A
Rationale: Nurses practice from the perspective of holism, which is viewing a person's health as a state balance between body, mind, and spirit. Leading an exercise, showing a video about healthy lifestyle changes, and inviting a spiritual leader to talk with the support group are all ways the nurse can meet the clients' needs holistically. By combining these activities, the nurse addresses the needs of the body, mind, and spirit. Cooking classes, having clients discuss stress reduction, and demonstrating exercise techniques are each only addressing one type of need, and therefore are not on their own holistic methods.