ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 1 : Concepts and Trends in Health Care Questions
Question 1 of 5
A group insurance plan requires a client to pay a present, fixed fee for healthcare services. What type of insurance plan does the nurse understand the client to have?
Correct Answer: B
Rationale: An HMO is a group insurance plan in which participants pay a preset, fixed fee in exchange for healthcare services. The fee is not based on the number of services provided but rather is projected to the number of participants and expected services. A PPO operates on the principle that competition can control costs. Acting as agents for health insurance companies, PPOs create a community network of providers who are willing to discount their fees for service in exchange for a steady stream of referred customers. Medicare is for people that are age 65 years and older or disabled. Medicaid is coverage for those clients who are unable to afford healthcare.
Question 2 of 5
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?
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.
Question 3 of 5
What does the nurse understand is the focus of healthcare when a client receives services from a health maintenance organization (HMO)?
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.
Question 4 of 5
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?
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.
Question 5 of 5
A client undergoing a surgical procedure at the hospital died related to complications during the procedure. The nurse is required to collect data about the event so that a cause can be determined. What type of quality indicators would be used in this incident?
Correct Answer: B
Rationale: Inpatient QIs reflect quality of care inside hospitals, including inpatient mortality for medical conditions and surgical procedures. Prevention QIs identify hospital admissions that could be avoided through high-quality outpatient care. Client safety QIs also reflect quality of care within hospitals but focus on potentially avoidable complications and adverse events. Pediatric QIs reflect quality of care inside hospitals and identify potentially avoidable hospitalization among children.