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Quiz: Care Coordination: PCMH and Team-Based Care

By Nancy Kimmel, MSN, FNP / July 2, 2026

Quiz: Care Coordination: PCMH and Team-Based Care

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Question 1 of 80

1. Question

A 65-year-old patient with diabetes and hypertension is being discharged from the hospital. In a PCMH model, who is primarily responsible for coordinating the patient’s follow-up care with their primary care provider and specialists?

The patient
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The hospital discharge planner
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The patient's primary care team
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The patient's insurance company
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Question 2 of 80

2. Question

A CCMA is preparing a patient for an examination. The patient mentions that they are having trouble affording their new medication. What is the most appropriate action for the CCMA to take?

Tell the patient not to worry about it.
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Document the patient's concern in the EHR and inform the provider.
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Give the patient a discount coupon for the medication.
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Advise the patient to switch to a cheaper medication.
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Question 3 of 80

3. Question

A patient is new to a PCMH practice. How would the CCMA best explain the role of the healthcare team?

"You will only see the doctor during your visits."
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"We have a team of professionals who will work together with you to manage your health."
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"You will need to coordinate your own care with different specialists."
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"The nurse will handle all of your questions and concerns."
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Question 4 of 80

4. Question

A patient with a complex chronic condition feels overwhelmed by their care plan. How can the CCMA, as part of the care team, help to empower the patient?

By telling the patient to just follow the doctor's orders.
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By providing the patient with educational materials and reinforcing the provider's instructions.
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By making all the decisions for the patient.
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By referring the patient to a different practice.
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Question 5 of 80

5. Question

A primary care practice is trying to improve its team-based care model. Which of the following strategies would be most effective?

Having each team member work independently to avoid confusion.
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Implementing daily team huddles to discuss patient care plans.
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Limiting communication between team members to email only.
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Assigning all care coordination tasks to the physicians.
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Question 6 of 80

6. Question

In a team-based care model, who is at the center of the care team?

The physician
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The nurse
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The CCMA
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The patient
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Question 7 of 80

7. Question

The mnemonic “C-C-CAPS” is used to remember the core functions of the PCMH. What does the “A” in “C-C-CAPS” stand for?

Accountable
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Accessible
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Affordable
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Administrative
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Question 8 of 80

8. Question

Which of the following is a primary benefit of the PCMH model for patients?

Increased healthcare costs
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Longer wait times for appointments
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A stronger relationship with their clinical care team
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Less involvement in their own care
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Question 9 of 80

9. Question

Which of the following is NOT a core function of the Patient-Centered Medical Home (PCMH) model?

Comprehensive Care
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Provider-Centered Care
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Coordinated Care
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Accessible Services
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Question 10 of 80

10. Question

Which of the following tasks is a CCMA most likely to perform in a team-based care setting?

Diagnosing a patient's condition
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Prescribing medication
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Scheduling a referral to a specialist
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Performing surgery
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Question 11 of 80

11. Question

A CCMA is cleaning an examination room after seeing a patient with C. difficile. What is the most important step in this process?

Wiping down surfaces with a standard alcohol-based disinfectant.
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Using a bleach-based solution or other sporicidal agent.
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Airing out the room for 30 minutes.
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Double-bagging all trash from the room.
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Question 12 of 80

12. Question

A CCMA is counseling a 22-year-old patient on preventing sexually transmitted infections (STIs). Which of the following is the most crucial point to emphasize?

The importance of annual physical exams
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The consistent use of barrier methods like condoms
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The need for a monogamous relationship
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The benefits of the HPV vaccine
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Question 13 of 80

13. Question

A CCMA is taking a patient’s history and learns the patient has not had a flu shot this season. The patient states, “I never get the flu, so I don’t need it.” What is the CCMA’s best response?

"That's a risky attitude to have."
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"It's a clinic policy that all patients get a flu shot."
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"The flu shot is recommended for everyone each year, as the virus changes. It not only protects you but also vulnerable people around you who could get very sick."
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"Okay, I will just document that you refused it."
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Question 14 of 80

14. Question

A medical assistant is educating a patient about the chain of infection. Which of the following represents the ‘reservoir’ in the chain?

The influenza virus
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A contaminated countertop
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A sneeze from an infected person
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An unvaccinated individual
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Question 15 of 80

15. Question

A medical assistant is preparing to assist with a minor surgical procedure that may involve splashing of bodily fluids. According to Standard Precautions, which combination of PPE is required?

Gloves only
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Gloves and a surgical mask
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Gloves, gown, and eye protection
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N95 respirator and gown
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Question 16 of 80

16. Question

A medical assistant is responsible for sterilizing surgical instruments. Which method is most appropriate for achieving surgical asepsis?

Soaking instruments in a high-level disinfectant.
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Wiping instruments with 70% isopropyl alcohol.
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Using an autoclave.
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Boiling instruments in water for 15 minutes.
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Question 17 of 80

17. Question

A mother is hesitant to vaccinate her child, stating she read online that vaccines cause autism. How should the medical assistant respond?

"That is a myth that has been debunked. You must vaccinate your child."
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"I understand your concern. Many parents see conflicting information. Let me give you a Vaccine Information Statement from the CDC that explains the proven safety of vaccines."
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"You are putting your child and others at risk by not vaccinating."
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"It's your choice, but I would vaccinate my child."
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Question 18 of 80

18. Question

A patient calls the clinic and says they were just bitten by a stray dog. What is the most appropriate initial instruction for the CCMA to give the patient?

"Come to the clinic immediately for a rabies shot."
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"Wash the wound thoroughly with soap and water and then come to the clinic or an urgent care center for evaluation."
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"Apply a tourniquet and wait for an ambulance."
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"Don't worry, most stray dogs don't have rabies."
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Question 19 of 80

19. Question

A patient with suspected tuberculosis is in the examination room. Which of the following actions by the CCMA is most appropriate?

Wear a surgical mask and gloves.
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Place the patient in a room with positive air pressure.
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Wear a fitted N95 respirator.
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Implement Droplet Precautions.
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Question 20 of 80

20. Question

Which of the following is an example of breaking the chain of infection at the ‘portal of entry’ link?

A chef washing their hands before handling food.
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A nurse wearing gloves to change a dressing on a wound.
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A hiker wearing insect repellent in a wooded area.
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Covering a wound with a sterile bandage.
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Question 21 of 80

21. Question

A CCMA is documenting a referral in the patient’s electronic health record (EHR). Which of the following pieces of information is LEAST critical to include in the documentation?

The date and time the referral was sent.
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The name of the staff member at the specialist's office who was contacted.
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The insurance authorization number.
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The CCMA's personal opinion of the specialist.
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Question 22 of 80

22. Question

A CCMA is using the “I-CARE” mnemonic to manage a referral. The “E” in the mnemonic stands for “Ensure follow-up.” What specific action does this step involve?

Ensuring the patient has transportation to the appointment.
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Ensuring the provider has signed the referral order.
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Ensuring the specialist's office received the patient's records.
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Ensuring the primary care office receives the specialist's consultation report.
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Question 23 of 80

23. Question

A new patient who is a refugee needs a variety of non-clinical support services. The CCMA is compiling a list of resources. Which type of organization would be the most comprehensive starting point?

A local hospital's billing department.
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A specialized agency for refugee assistance.
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The Social Security Administration office.
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The local chamber of commerce.
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Question 24 of 80

24. Question

A patient is being referred to a specialist by their PCP. The CCMA is preparing the referral form. Which piece of information is essential to include to justify the medical necessity of the referral?

The patient's preferred appointment time.
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The referring provider's NPI number.
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The patient's diagnosis and relevant ICD-10 code.
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The specialist's office fax number.
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Question 25 of 80

25. Question

A patient with an HMO insurance plan needs a referral to a dermatologist. The CCMA finds a highly-rated dermatologist nearby but they are not in the patient’s insurance network. What is the most appropriate action for the CCMA?

Schedule the appointment anyway, as the doctor is highly rated.
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Inform the patient that they must pay out-of-pocket.
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Find an in-network dermatologist and confirm with the provider before proceeding.
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Tell the patient their insurance will not cover any dermatology services.
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Question 26 of 80

26. Question

A patient with diabetes mentions they have trouble getting to their appointments due to a lack of reliable transportation. Which of the following community resources would be most appropriate for the CCMA to suggest?

Supplemental Nutrition Assistance Program (SNAP)
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Non-emergency medical transportation (NEMT)
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A local grief support group
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The patient's health insurance company
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Question 27 of 80

27. Question

A provider gives a CCMA a verbal order for a STAT referral for a patient with a suspected deep vein thrombosis (DVT). What does the “STAT” designation require the CCMA to do?

Complete the referral by the end of the week.
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Initiate the referral process immediately and with urgency.
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Wait for the provider to write the order in the chart.
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Ask the patient to call the specialist themselves.
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Question 28 of 80

28. Question

A provider instructs the CCMA to refer a patient to a cardiologist for evaluation of chest pain. What is the CCMA’s first step after acknowledging the order?

Schedule the appointment with the cardiologist.
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Contact the patient's insurance company to obtain prior authorization.
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Send the patient's medical records to the specialist.
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Give the patient the cardiologist's phone number.
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Question 29 of 80

29. Question

The process of tracking a referral to make sure the patient attended their appointment and that the PCP received the specialist’s report is commonly referred to as:

Closing the loop.
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Initiating the transfer.
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Obtaining authorization.
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Documenting the order.
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Question 30 of 80

30. Question

When a CCMA is identifying community resources for a patient who has expressed financial hardship, which of the following would be the LEAST relevant to investigate?

Local food banks and pantries.
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Utility and rental assistance programs.
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Public library schedules and events.
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Medicaid and CHIP application assistance.
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Question 31 of 80

31. Question

A CCMA is using the teach-back method while educating a patient about their new inhaler. Which statement by the CCMA demonstrates correct use of this method?

"Do you have any questions about the inhaler?"
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"I want to be sure I explained this clearly. Can you show me how you are going to use the inhaler?"
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"You understand how to use the inhaler, right?"
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"Make sure you read the instructions when you get home."
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Question 32 of 80

32. Question

A patient calls the office and states they stopped taking their new blood pressure medication because it gives them a dry cough. How should the CCMA respond?

Advise the patient to restart the medication immediately.
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Schedule an appointment for the patient to see the provider and advise them to continue the medication in the meantime.
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Inform the patient that this is a common side effect and they should get used to it.
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Advise the patient to continue to hold the medication and that you will relay the information to the provider for further instructions.
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Question 33 of 80

33. Question

A patient with a history of deep vein thrombosis (DVT) is prescribed an anticoagulant. They tell the CCMA they often forget to take it on the weekends. Why is this particularly dangerous?

It can cause the patient to develop a resistance to the medication.
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It can lead to an increased risk of bleeding when they resume the medication.
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It can result in subtherapeutic levels of the medication, increasing the risk of clot formation.
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It will cause unpleasant withdrawal symptoms.
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Question 34 of 80

34. Question

A patient with COPD tells the CCMA, “I only use my maintenance inhaler when I feel short of breath.” What is the most critical concept the CCMA needs to reinforce?

The inhaler will work faster if used every day.
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The difference between a maintenance (controller) inhaler and a rescue inhaler.
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The patient can save money by not using the inhaler daily.
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The patient should request a pill form of the medication instead.
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Question 35 of 80

35. Question

A patient with newly diagnosed diabetes is having trouble remembering to take their metformin. Which of the following would be the most effective initial strategy for the CCMA to suggest?

Telling the patient to try harder to remember.
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Suggesting they link the medication dose to a daily activity, like breakfast.
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Asking the provider to prescribe a different medication.
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Documenting the non-compliance in the patient's chart.
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Question 36 of 80

36. Question

According to the unit content, approximately what percentage of filled prescriptions are taken incorrectly?

20%
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30%
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50%
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75%
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Question 37 of 80

37. Question

An elderly patient with hypertension and diabetes has a complex medication regimen with 8 different prescriptions. What is the most practical tool a CCMA can help create to improve their adherence?

A handwritten list of the medications.
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A detailed weekly pill organizer.
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A series of daily phone call reminders.
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A brochure on hypertension.
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Question 38 of 80

38. Question

During a rooming process, a patient mentions they sometimes cut their cholesterol pills in half to make the prescription last longer due to cost. What is the most appropriate action for the CCMA to take?

Tell the patient that pill-splitting is a good way to save money.
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Document the patient's statement and notify the provider.
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Give the patient a list of local food banks.
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Advise the patient to stop taking the medication altogether if they cannot afford it.
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Question 39 of 80

39. Question

The ‘C’ in the CARE mnemonic for patient education stands for:

Cost
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Clarify
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Compliance
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Chronic
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Question 40 of 80

40. Question

Which of the following best defines medication adherence?

The patient's ability to afford their prescribed medications.
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The extent to which a patient takes their medication as prescribed by their provider.
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The act of a provider prescribing the most effective medication.
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A patient's satisfaction with their treatment plan.
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Question 41 of 80

41. Question

A CCMA is discussing the importance of hydration with a patient. The CCMA should explain that water is essential for which of the following?

Regulating body temperature
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Storing energy
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Building muscle
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Producing hormones
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Question 42 of 80

42. Question

A CCMA is educating a patient on the MyPlate model. Which of the following food groups should make up the largest portion of the plate?

Fruits
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Grains
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Vegetables
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Protein
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Question 43 of 80

43. Question

A CCMA is providing education to a patient about the benefits of regular physical activity. Which of the following is a benefit of exercise?

Increased risk of chronic diseases
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Weight gain
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Improved cardiovascular health
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Decreased energy levels
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Question 44 of 80

44. Question

A CCMA is reinforcing teaching with a patient about healthy lifestyle changes. Which of the following patient statements indicates an understanding of the teaching?

"I will start by running a marathon next month."
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"I will aim to eat at least five servings of fruits and vegetables daily."
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"I will eat whatever I want and just take more medication."
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"I don't need to exercise because I am not overweight."
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Question 45 of 80

45. Question

A CCMA is reinforcing teaching with a patient about portion control. Which of the following is a good visual cue for a single serving of protein?

A deck of cards
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A baseball
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A golf ball
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A postage stamp
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Question 46 of 80

46. Question

A CCMA is reviewing a patient’s food diary. The patient reports eating a lot of processed foods and sugary drinks. The CCMA should identify that this patient is at risk for which of the following conditions?

Anemia
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Osteoporosis
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Type 2 diabetes
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Hypothyroidism
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Question 47 of 80

47. Question

A CCMA is using the “N.E.W. S.T.A.R.T.” mnemonic to educate a patient about healthy lifestyle changes. The “T” in the mnemonic stands for which of the following?

Time management
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Think positively
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Take medication
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Talk to friends
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Question 48 of 80

48. Question

A CCMA is working with a patient who is struggling to make lifestyle changes. The patient states, “I’ve tried to lose weight so many times, but I always fail.” Which of the following is the most appropriate response by the CCMA?

"You're right, it's probably not worth trying again."
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"Maybe you're just not meant to be thin."
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"It sounds like you're feeling discouraged. Let's talk about some small changes you can make that will be more manageable."
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"You just need to have more willpower."
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Question 49 of 80

49. Question

A patient asks the CCMA for advice on how to start an exercise program. The patient has a history of cardiovascular disease. Which of the following is the most appropriate response by the CCMA?

"You should start with high-intensity interval training."
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"You should advise the patient to consult with their provider before starting any new exercise program."
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"You should tell the patient to walk for 30 minutes every day."
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"You should give the patient a copy of your personal workout routine."
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Question 50 of 80

50. Question

A patient is trying to lose weight and asks the CCMA for advice on reading food labels. Which of the following should the CCMA tell the patient to look for?

Foods that are high in sodium and sugar.
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Foods that are low in fiber and protein.
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Foods that are high in saturated and trans fats.
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Foods that are low in calories, fat, and sodium, and high in fiber.
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Question 51 of 80

51. Question

A 25-year-old female patient is at the clinic for a non-urgent issue. Her record shows she has not had a Pap test before. What is the most likely action the Medical Assistant will take?

Perform a Pap test immediately.
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Inform the provider that the patient is due for a cervical cancer screening.
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Tell the patient she doesn't need one until she is 30.
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Schedule her for a mammogram at the same time.
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Question 52 of 80

52. Question

A 48-year-old patient with a BMI of 31 and a family history of diabetes is in for a check-up. Which screening is most critical to perform?

Cholesterol Panel
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Pap Test
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Diabetes Screening (A1c or Glucose)
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Vision Test
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Question 53 of 80

53. Question

A 52-year-old female patient is scheduled for her annual wellness visit. According to standard guidelines, which of the following cancer screenings should the Medical Assistant anticipate the provider will discuss?

Blood glucose test
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Mammogram
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Bone density scan
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Skin cancer screening
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Question 54 of 80

54. Question

A patient tells the Medical Assistant, “I don’t understand why I need a cholesterol test. I feel fine.” Which of the following is the most appropriate response?

"The doctor ordered it, so you have to do it."
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"It's a routine test everyone gets."
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"The test helps assess your risk for heart disease, even if you don't have symptoms."
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"You can refuse the test if you want to."
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Question 55 of 80

55. Question

A provider asks the Medical Assistant to give a patient some information on smoking cessation. Which of the following actions is the most appropriate?

Give the patient a brochure with resources for quitting smoking.
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Tell the patient that smoking is bad for their health.
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Share a personal story about quitting smoking.
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Schedule the patient for a follow-up in one year.
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Question 56 of 80

56. Question

According to the unit content, how often should a routine blood pressure screening be performed on an adult patient?

Every 2 years
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Every 5 years
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Annually
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Only when symptoms are present
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Question 57 of 80

57. Question

The memory anchor “SCREEN” is a tool to remember the components of a wellness visit. What does the ‘R’ in SCREEN stand for?

Referrals
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Risk Assessment
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Routine Check-up
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Results
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Question 58 of 80

58. Question

What is the primary role of a Medical Assistant in patient education regarding preventive care?

To diagnose conditions based on screening results.
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To prescribe lifestyle changes and medications.
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To provide information and reinforce the provider's recommendations.
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To order additional diagnostic tests.
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Question 59 of 80

59. Question

Which of the following tasks falls within the Medical Assistant’s scope of practice during a wellness screening?

Interpreting the results of a lipid panel.
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Performing a BMI calculation.
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Developing a new wellness plan for the patient.
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Diagnosing a patient with hypertension.
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Question 60 of 80

60. Question

Why is accurate documentation of wellness screenings in a patient’s electronic health record (EHR) so important?

It is the only way the clinic can bill for the service.
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It allows for tracking the patient's health over time and ensures appropriate follow-up.
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It is a legal requirement for all patient interactions.
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It helps the Medical Assistant practice their data entry skills.
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Question 61 of 80

61. Question

A CCMA is preparing a 72-year-old patient for their first-ever video consultation. Which of the following is the MOST important initial step?

Sending the appointment link via email.
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Collecting the copayment over the phone.
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Assessing the patient's technological capabilities and access.
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Documenting the patient's chief complaint in the EHR.
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Question 62 of 80

62. Question

A patient calls after a virtual visit, confused about the new medication the provider prescribed. The CCMA should:

Tell the patient to schedule another virtual visit with the provider.
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Access the visit summary and review the provider's instructions with the patient.
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Advise the patient to call the pharmacy for information.
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Look up the medication online and explain its side effects.
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Question 63 of 80

63. Question

A patient does not have a private space for their virtual visit and is in a public library. Which of the following is the best course of action for the CCMA?

Proceed with the visit but ask the patient to whisper.
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Reschedule the appointment for a time when the patient can be in a private location.
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Ask the patient to use the chat function to type their symptoms.
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Continue the visit but avoid discussing sensitive information.
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Question 64 of 80

64. Question

A patient is hesitant to use the patient portal to view their lab results after a virtual visit. How should the CCMA respond?

Tell the patient they must use the portal as it's the only option.
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Offer to walk the patient through the portal registration and login process.
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Mail a printed copy of the results to the patient's home.
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Instruct the patient to call back when the provider is available.
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Question 65 of 80

65. Question

A provider asks the CCMA to get a patient’s consent for a telehealth visit. The CCMA must ensure the patient understands:

That the visit will be recorded for training purposes.
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The potential risks and benefits of receiving care remotely.
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That insurance will not cover the virtual appointment.
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That they must have a blood pressure cuff at home.
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Question 66 of 80

66. Question

According to the VIRTUAL mnemonic, what does the ‘L’ stand for?

Listen to the patient's concerns.
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Link the patient to follow-up care.
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Limit the call time to 15 minutes.
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Log out of the EHR securely.
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Question 67 of 80

67. Question

During a virtual visit, the patient’s video feed suddenly freezes. What is the CCMA’s most appropriate action?

Immediately disconnect the call and reschedule.
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Ask the patient to restart their computer.
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Continue the visit using only audio.
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Remain calm, acknowledge the issue, and suggest simple troubleshooting steps.
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Question 68 of 80

68. Question

What is the primary purpose of the CCMA performing a virtual “rooming” process?

To bill for a higher level of service.
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To ensure the patient's video is working correctly.
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To gather and update patient information before the provider joins.
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To provide the patient with a diagnosis.
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Question 69 of 80

69. Question

Which of the following is a key component of good “webside manner”?

Using complex medical terminology to sound professional.
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Looking at the patient's image on the screen instead of the camera.
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Ensuring the background is a busy clinical setting to look authentic.
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Speaking clearly and looking into the camera to simulate eye contact.
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Question 70 of 80

70. Question

Which of these tasks is uniquely characteristic of a CCMA’s role in a virtual visit compared to an in-person visit?

Taking a patient's medical history.
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Scheduling a follow-up appointment.
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Conducting a pre-visit technology check.
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Documenting information in the EHR.
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Question 71 of 80

71. Question

A 72-year-old patient is being discharged from the hospital to a skilled nursing facility. The patient is hard of hearing and seems confused about their new care plan. What is the best approach for the CCMA to ensure the patient understands the instructions?

Speak very loudly and slowly to the patient.
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Give the written instructions to the patient's daughter who is present.
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Use the "teach-back" method and involve the patient's daughter in the conversation.
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Tell the patient to read the instructions carefully once they get to the new facility.
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Question 72 of 80

72. Question

A CCMA is preparing a patient for discharge after an appointment where a new medication was prescribed. Which action is the most critical for the CCMA to perform?

Handing the patient a brochure about the new medication.
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Performing medication reconciliation.
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Asking the patient if they have any questions.
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Documenting the new prescription in the chart.
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Question 73 of 80

73. Question

A patient is transitioning from a primary care physician (PCP) to a cardiologist. The CCMA’s role in this transition would most likely include:

Prescribing a new heart medication for the patient.
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Performing an electrocardiogram (ECG) and interpreting the results.
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Preparing the referral form and ensuring the patient's recent lab results and ECG reports are sent to the cardiologist's office.
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Advising the patient to stop taking their current blood pressure medication.
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Question 74 of 80

74. Question

A patient with diabetes is being discharged and needs to learn how to use a new glucose meter. The CCMA demonstrates how to use the device. To best assess the patient’s understanding, what should the CCMA do next?

Ask the patient, "Do you understand?"
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Have the patient demonstrate how to use the meter.
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Give the patient the instruction manual for the meter.
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Schedule a follow-up call for the next day.
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Question 75 of 80

75. Question

A primary care office is implementing a new process to improve its transition of care for patients referred to specialists. Which of the following actions would be the most effective improvement?

Creating a standardized referral form that includes a recent medication list and reason for referral.
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Giving patients the specialist's phone number and telling them to schedule their own appointment.
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Calling the specialist's office to give a verbal report on every referred patient.
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Sending the patient's entire medical record to the specialist's office.
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Question 76 of 80

76. Question

Analysis of a hospital’s readmission data shows that many patients are readmitted within 7 days due to medication errors. Which part of the transition of care process should be reviewed and improved first?

The patient transportation services.
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The process for medication reconciliation at discharge.
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The hospital's dietary menu options.
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The scheduling of post-discharge physical therapy.
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Question 77 of 80

77. Question

The mnemonic “CARE” is a tool to remember key steps in care transitions. What does the ‘R’ in CARE stand for?

Refer
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Reconcile
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Report
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Reinforce
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Question 78 of 80

78. Question

What is the primary goal of a transition of care?

To discharge patients from the hospital as quickly as possible.
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To ensure the coordination and continuity of healthcare for patient safety.
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To reduce the number of follow-up appointments a patient needs.
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To transfer all administrative tasks to the patient's family.
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Question 79 of 80

79. Question

Which of the following is NOT a core component of a continuity of care plan?

Scheduling follow-up appointments.
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Patient's preference for the hospital's cafeteria menu.
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A reconciled list of the patient's medications.
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Education on signs and symptoms to watch for at home.
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Question 80 of 80

80. Question

Which of the following situations represents a potential barrier to a successful transition of care?

The patient, their family, and the healthcare team are all involved in discharge planning.
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The discharging hospital and the receiving home health agency use the same electronic health record (EHR) system.
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The patient is discharged on a Friday afternoon with a new prescription that needs prior authorization.
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The CCMA calls the patient two days after discharge to check on their progress.
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