NURS4065 – Patient-Centered Care Coordination
Midterm Examination Questions & Answers
Question 1
A nurse is coordinating care for a patient with multiple chronic conditions being
discharged from the hospital. Which action best demonstrates patient-centered care
coordination?
A) Developing a discharge plan without patient input to save time
B) Engaging the patient and family in shared decision-making, identifying goals,
and creating a transition plan aligned with patient preferences
C) Discharging the patient without follow-up appointments
D) Focusing only on medical needs, ignoring social and mental health factors
Answer: B) Engaging the patient and family in shared decision-making,
identifying goals, and creating a transition plan aligned with patient
preferences
Patient-centered care coordination places the patient and family at the center of
decision-making. It respects their values, preferences, and goals, and integrates
medical, social, and mental health needs.
Question 2
A nurse is using the “Transitional Care Model” (TCM) developed by Mary Naylor.
Which intervention is a core component of TCM?
A) Discharging patients without follow-up
B) Advanced practice nurse-led care coordination from hospital to home, including
home visits and telephone follow-up
C) Sending a single letter to the primary care provider
D) Avoiding any contact after discharge
,Answer: B) Advanced practice nurse-led care coordination from hospital to
home, including home visits and telephone follow-up
The Transitional Care Model (TCM) uses an advanced practice nurse to coordinate
care across transitions, including hospital admission, discharge, and home follow-
up with telephone calls and home visits. It reduces readmissions.
Question 3
A nurse is conducting a “medication reconciliation” at hospital admission. Which
statement best describes the purpose of medication reconciliation?
A) To discontinue all home medications
B) To create an accurate, complete list of a patient’s current medications and
compare with admission orders to prevent discrepancies
C) To increase the number of medications prescribed
D) To bill insurance for medications
Answer: B) To create an accurate, complete list of a patient’s current
medications and compare with admission orders to prevent discrepancies
Medication reconciliation is a National Patient Safety Goal. It identifies unintended
discrepancies (omissions, duplications, dosing errors) at transitions of care
(admission, transfer, discharge).
Question 4
A care coordinator is working with a patient with heart failure who has been
readmitted three times in six months. Which evidence-based intervention is most
likely to reduce readmissions?
A) Discharging without a follow-up appointment
B) A structured transitional care program including a post-discharge phone call
within 48 hours and a clinic visit within 7 days
C) Increasing the dose of diuretics at discharge
D) Sending the patient home with no education
,Answer: B) A structured transitional care program including a post-discharge
phone call within 48 hours and a clinic visit within 7 days
Early follow-up (within 7 days), medication reconciliation, patient education, and
timely communication with primary care reduce heart failure readmissions. The
transitional care model is evidence-based.
Question 5
A nurse is using the “Chronic Care Model” (CCM) to redesign care for patients
with diabetes. Which component of the CCM involves self-management support?
A) Replacing all patient decisions with provider decisions
B) Empowering patients with skills, tools, and confidence to manage their own
condition
C) Limiting patient access to health information
D) Focusing only on acute episodic care
Answer: B) Empowering patients with skills, tools, and confidence to manage
their own condition
The Chronic Care Model includes self-management support, delivery system
redesign, decision support, clinical information systems, community resources, and
health system organization. Self-management support is central to patient-centered
care.
Question 6
A nurse is coordinating care for a patient with limited English proficiency. Which
action is essential for effective care coordination?
A) Using the patient’s family member as an interpreter
B) Providing a qualified medical interpreter (in-person or via video/telephone) to
ensure accurate communication
C) Speaking loudly in English
D) Ignoring language barriers
, Answer: B) Providing a qualified medical interpreter (in-person or via
video/telephone) to ensure accurate communication
Title VI of the Civil Rights Act requires healthcare providers to offer qualified
interpreters for patients with limited English proficiency. Family members or
untrained staff may compromise accuracy and confidentiality.
Question 7
A care coordinator is developing a “transition plan” for a patient being discharged
after a stroke. Which element is critical to include?
A) No follow-up appointments
B) A summary of the hospital stay, medication list, follow-up appointments,
warning signs to watch for, and contact information
C) Only the discharge date
D) A list of hospital cafeteria options
Answer: B) A summary of the hospital stay, medication list, follow-up
appointments, warning signs to watch for, and contact information
A comprehensive discharge plan includes: diagnosis, procedures, medication
changes, pending tests, follow-up appointments, red flags (symptoms that require
medical attention), and whom to call. It should be written in plain language and
reviewed with the patient.
Question 8
A nurse is using the “teach-back” method to confirm a patient’s understanding of
discharge instructions. Which question best demonstrates teach-back?
A) “Do you understand what I told you?”
B) “Please tell me in your own words what you will do when you get home to take
care of your blood pressure.”
C) “Are you listening?”
D) “I hope you remember this.”
Midterm Examination Questions & Answers
Question 1
A nurse is coordinating care for a patient with multiple chronic conditions being
discharged from the hospital. Which action best demonstrates patient-centered care
coordination?
A) Developing a discharge plan without patient input to save time
B) Engaging the patient and family in shared decision-making, identifying goals,
and creating a transition plan aligned with patient preferences
C) Discharging the patient without follow-up appointments
D) Focusing only on medical needs, ignoring social and mental health factors
Answer: B) Engaging the patient and family in shared decision-making,
identifying goals, and creating a transition plan aligned with patient
preferences
Patient-centered care coordination places the patient and family at the center of
decision-making. It respects their values, preferences, and goals, and integrates
medical, social, and mental health needs.
Question 2
A nurse is using the “Transitional Care Model” (TCM) developed by Mary Naylor.
Which intervention is a core component of TCM?
A) Discharging patients without follow-up
B) Advanced practice nurse-led care coordination from hospital to home, including
home visits and telephone follow-up
C) Sending a single letter to the primary care provider
D) Avoiding any contact after discharge
,Answer: B) Advanced practice nurse-led care coordination from hospital to
home, including home visits and telephone follow-up
The Transitional Care Model (TCM) uses an advanced practice nurse to coordinate
care across transitions, including hospital admission, discharge, and home follow-
up with telephone calls and home visits. It reduces readmissions.
Question 3
A nurse is conducting a “medication reconciliation” at hospital admission. Which
statement best describes the purpose of medication reconciliation?
A) To discontinue all home medications
B) To create an accurate, complete list of a patient’s current medications and
compare with admission orders to prevent discrepancies
C) To increase the number of medications prescribed
D) To bill insurance for medications
Answer: B) To create an accurate, complete list of a patient’s current
medications and compare with admission orders to prevent discrepancies
Medication reconciliation is a National Patient Safety Goal. It identifies unintended
discrepancies (omissions, duplications, dosing errors) at transitions of care
(admission, transfer, discharge).
Question 4
A care coordinator is working with a patient with heart failure who has been
readmitted three times in six months. Which evidence-based intervention is most
likely to reduce readmissions?
A) Discharging without a follow-up appointment
B) A structured transitional care program including a post-discharge phone call
within 48 hours and a clinic visit within 7 days
C) Increasing the dose of diuretics at discharge
D) Sending the patient home with no education
,Answer: B) A structured transitional care program including a post-discharge
phone call within 48 hours and a clinic visit within 7 days
Early follow-up (within 7 days), medication reconciliation, patient education, and
timely communication with primary care reduce heart failure readmissions. The
transitional care model is evidence-based.
Question 5
A nurse is using the “Chronic Care Model” (CCM) to redesign care for patients
with diabetes. Which component of the CCM involves self-management support?
A) Replacing all patient decisions with provider decisions
B) Empowering patients with skills, tools, and confidence to manage their own
condition
C) Limiting patient access to health information
D) Focusing only on acute episodic care
Answer: B) Empowering patients with skills, tools, and confidence to manage
their own condition
The Chronic Care Model includes self-management support, delivery system
redesign, decision support, clinical information systems, community resources, and
health system organization. Self-management support is central to patient-centered
care.
Question 6
A nurse is coordinating care for a patient with limited English proficiency. Which
action is essential for effective care coordination?
A) Using the patient’s family member as an interpreter
B) Providing a qualified medical interpreter (in-person or via video/telephone) to
ensure accurate communication
C) Speaking loudly in English
D) Ignoring language barriers
, Answer: B) Providing a qualified medical interpreter (in-person or via
video/telephone) to ensure accurate communication
Title VI of the Civil Rights Act requires healthcare providers to offer qualified
interpreters for patients with limited English proficiency. Family members or
untrained staff may compromise accuracy and confidentiality.
Question 7
A care coordinator is developing a “transition plan” for a patient being discharged
after a stroke. Which element is critical to include?
A) No follow-up appointments
B) A summary of the hospital stay, medication list, follow-up appointments,
warning signs to watch for, and contact information
C) Only the discharge date
D) A list of hospital cafeteria options
Answer: B) A summary of the hospital stay, medication list, follow-up
appointments, warning signs to watch for, and contact information
A comprehensive discharge plan includes: diagnosis, procedures, medication
changes, pending tests, follow-up appointments, red flags (symptoms that require
medical attention), and whom to call. It should be written in plain language and
reviewed with the patient.
Question 8
A nurse is using the “teach-back” method to confirm a patient’s understanding of
discharge instructions. Which question best demonstrates teach-back?
A) “Do you understand what I told you?”
B) “Please tell me in your own words what you will do when you get home to take
care of your blood pressure.”
C) “Are you listening?”
D) “I hope you remember this.”
