Relias Case Management Assessment A EXAM with
Questions and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
EXAM COVERAGE
1. Psychosocial Assessment, Patient Crisis Intervention, and Risk Mitigation
2. Utilization Management, Prior Authorization, and Insurance Regulations
3. Care Transitions, Discharge Planning, and Complex Resource Coordination
4. Ethical Standards, HIPAA Compliance, and Professional Boundaries
5. Social Determinants of Health (SDOH) and Population Health Metrics
1. A patient receives a terminal cancer diagnosis and is found crying in their hospital room. They
state they recently experienced a divorce and have no family members in the local area. What is
the nurse case manager's priority action?
A. Recommend immediate discharge to an outpatient rehabilitation facility to limit hospital
length of stay.
B. Comfort the patient, listen to their concerns, and initiate referrals to inpatient
psychosocial services and an oncology nurse navigator.
C. Contact the legal department immediately to discuss advanced directive documentation and
power of attorney assignment.
D. Advise the patient to suppress their emotional distress to maintain unit decorum and focus on
medical treatments.
CORRECT ANSWER : B
Rationale: Emotional distress and acute crisis following a terminal diagnosis require immediate
empathetic support, active listening, and multidisciplinary coordination to integrate
psychosocial resources and navigation support. Options A and C fail to address the immediate
psychological crisis appropriately. Option D invalidates the patient's emotional experience.
,2. During a psychosocial assessment of a 6-year-old pediatric patient, a nurse case manager
discovers suspicious patterns of frequent, unexplained hospitalizations that do not match clinical
findings, suspecting Munchausen by Syndrome by Proxy. What priority actions must the case
manager take?
A. Confront the parent aggressively in the hallway and demand an immediate explanation for the
conflicting medical history.
B. Immediately alert the patient's care team, report suspicions to Child Protective Services,
document findings objectively, and request a psychiatric consult to safeguard the child.
C. Discharge the patient immediately to home care without notifying authorities to avoid parental
conflict.
D. Maintain complete confidentiality and rely solely on outpatient pediatric follow-up
appointments.
CORRECT ANSWER : B
Rationale: Suspected child abuse or Munchausen by Proxy requires immediate interprofessional
notification, mandatory reporting to Child Protective Services, detailed clinical documentation,
and protective oversight (such as a sitter or psychiatry consult) to protect the child from
imminent harm. Confrontation or premature discharge places the child at severe risk.
3. A case manager notices that a personal family friend appears on their active patient caseload.
Realizing this constitutes a conflict of interest, the manager quickly reviews the patient's
electronic health record out of personal curiosity before reassigning the case. What major legal
act has the case manager violated?
A. Emergency Medical Treatment and Labor Act (EMTALA)
B. Health Insurance Portability and Accountability Act (HIPAA)
C. Affordable Care Act (ACA)
D. Americans with Disabilities Act (ADA)
CORRECT ANSWER : B
Rationale: Accessing a medical record without a direct, legitimate professional need-to-know—
even for a personal acquaintance—constitutes a breach of patient privacy and violates the
Health Insurance Portability and Accountability Act (HIPAA). None of the other listed acts
govern unauthorized record viewing.
,4. A case manager is working with the family of a school-aged child with complex special needs
who is anxious about potential bullying upon entering a new school district. Which collaborative
communication and planning tool should the case manager recommend?
A. Individualized Education Program (IEP) review without parental participation.
B. Admission, Review, and Dismissal (ARD) committee meeting or specialized school
transition planning conference.
C. Routine pediatric well-child checkup documentation.
D. Direct legal summons to the school district board of education.
CORRECT ANSWER : B
Rationale: An Admission, Review, and Dismissal (ARD) committee or structured school planning
conference facilitates proactive communication between parents, medical providers, and school
personnel to establish accommodations and bullying prevention strategies before school starts.
5. A patient with a pre-existing medical condition purchased an individual health insurance policy
online directly from a private carrier outside of the official Health Insurance Market Exchange
covered under the Affordable Care Act (ACA). The patient is upset that their plan enforces a 6-
month waiting period for pre-existing conditions. What is the case manager's most accurate
response?
A. "The ACA mandates that all private insurance plans eliminate pre-existing condition
exclusions immediately regardless of purchase venue."
B. "Plans acquired directly from private carriers outside the Healthcare Market Exchange
operate under different terms and conditions, which may include waiting periods for pre-
existing conditions."
C. "You can sue the insurance carrier for federal fraud because pre-existing condition bans are
universally illegal."
D. "Your hospital case manager can override the private insurance policy rules by executive
decree."
CORRECT ANSWER : B
Rationale: Health insurance plans purchased outside the official Health Insurance Market
Exchange established under the ACA do not necessarily adhere to all ACA consumer
protections, meaning they may retain waiting periods or exclusions for pre-existing conditions.
6. A case manager is evaluating a frail older adult client to determine functional independence
levels. Which three core domains comprise a comprehensive functional status assessment?
, A. Blood pressure, heart rate, and temperature trends.
B. Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), and
Mobility (fall risk).
C. Occupational history, credit score, and marital status.
D. Genomic sequencing, viral titers, and metabolic panels.
CORRECT ANSWER : B
Rationale: A functional status assessment evaluates a patient's self-care abilities via Activities of
Daily Living (ADLs), complex independent living tasks via Instrumental Activities of Daily
Living (IADLs), and physical stability through mobility and fall risk screens.
7. A case manager is utilizing aggregated diagnosis groups (ADGs) to classify a patient's health
status and resource utilization profile. In which primary category would an acute localized skin
infection be classified?
A. Surgical intervention complexity index
B. Disease etiology and clinical manifestation category
C. Financial billing reimbursement tier
D. Hospital readmission penalty matrix
CORRECT ANSWER : B
Rationale: Aggregated Diagnosis Groups (ADGs) categorize patient disease profiles based on
disease etiology and expected clinical severity to predict healthcare utilization and resource
needs.
8. A clinically stable patient requires continuous intravenous infusion therapy upon discharge
home. In preparing the care transition plan, what is the most appropriate care delivery workflow
for the case manager to implement?
A. Discontinue all intravenous lines and instruct the patient to take oral fluids exclusively.
B. Ensure a PICC line or central venous access is placed prior to discharge, then
coordinate care with an accredited ambulatory infusion care center or home health nursing
agency.
C. Send the patient home without vascular access and expect emergency room staff to manage
daily infusions.
Questions and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
EXAM COVERAGE
1. Psychosocial Assessment, Patient Crisis Intervention, and Risk Mitigation
2. Utilization Management, Prior Authorization, and Insurance Regulations
3. Care Transitions, Discharge Planning, and Complex Resource Coordination
4. Ethical Standards, HIPAA Compliance, and Professional Boundaries
5. Social Determinants of Health (SDOH) and Population Health Metrics
1. A patient receives a terminal cancer diagnosis and is found crying in their hospital room. They
state they recently experienced a divorce and have no family members in the local area. What is
the nurse case manager's priority action?
A. Recommend immediate discharge to an outpatient rehabilitation facility to limit hospital
length of stay.
B. Comfort the patient, listen to their concerns, and initiate referrals to inpatient
psychosocial services and an oncology nurse navigator.
C. Contact the legal department immediately to discuss advanced directive documentation and
power of attorney assignment.
D. Advise the patient to suppress their emotional distress to maintain unit decorum and focus on
medical treatments.
CORRECT ANSWER : B
Rationale: Emotional distress and acute crisis following a terminal diagnosis require immediate
empathetic support, active listening, and multidisciplinary coordination to integrate
psychosocial resources and navigation support. Options A and C fail to address the immediate
psychological crisis appropriately. Option D invalidates the patient's emotional experience.
,2. During a psychosocial assessment of a 6-year-old pediatric patient, a nurse case manager
discovers suspicious patterns of frequent, unexplained hospitalizations that do not match clinical
findings, suspecting Munchausen by Syndrome by Proxy. What priority actions must the case
manager take?
A. Confront the parent aggressively in the hallway and demand an immediate explanation for the
conflicting medical history.
B. Immediately alert the patient's care team, report suspicions to Child Protective Services,
document findings objectively, and request a psychiatric consult to safeguard the child.
C. Discharge the patient immediately to home care without notifying authorities to avoid parental
conflict.
D. Maintain complete confidentiality and rely solely on outpatient pediatric follow-up
appointments.
CORRECT ANSWER : B
Rationale: Suspected child abuse or Munchausen by Proxy requires immediate interprofessional
notification, mandatory reporting to Child Protective Services, detailed clinical documentation,
and protective oversight (such as a sitter or psychiatry consult) to protect the child from
imminent harm. Confrontation or premature discharge places the child at severe risk.
3. A case manager notices that a personal family friend appears on their active patient caseload.
Realizing this constitutes a conflict of interest, the manager quickly reviews the patient's
electronic health record out of personal curiosity before reassigning the case. What major legal
act has the case manager violated?
A. Emergency Medical Treatment and Labor Act (EMTALA)
B. Health Insurance Portability and Accountability Act (HIPAA)
C. Affordable Care Act (ACA)
D. Americans with Disabilities Act (ADA)
CORRECT ANSWER : B
Rationale: Accessing a medical record without a direct, legitimate professional need-to-know—
even for a personal acquaintance—constitutes a breach of patient privacy and violates the
Health Insurance Portability and Accountability Act (HIPAA). None of the other listed acts
govern unauthorized record viewing.
,4. A case manager is working with the family of a school-aged child with complex special needs
who is anxious about potential bullying upon entering a new school district. Which collaborative
communication and planning tool should the case manager recommend?
A. Individualized Education Program (IEP) review without parental participation.
B. Admission, Review, and Dismissal (ARD) committee meeting or specialized school
transition planning conference.
C. Routine pediatric well-child checkup documentation.
D. Direct legal summons to the school district board of education.
CORRECT ANSWER : B
Rationale: An Admission, Review, and Dismissal (ARD) committee or structured school planning
conference facilitates proactive communication between parents, medical providers, and school
personnel to establish accommodations and bullying prevention strategies before school starts.
5. A patient with a pre-existing medical condition purchased an individual health insurance policy
online directly from a private carrier outside of the official Health Insurance Market Exchange
covered under the Affordable Care Act (ACA). The patient is upset that their plan enforces a 6-
month waiting period for pre-existing conditions. What is the case manager's most accurate
response?
A. "The ACA mandates that all private insurance plans eliminate pre-existing condition
exclusions immediately regardless of purchase venue."
B. "Plans acquired directly from private carriers outside the Healthcare Market Exchange
operate under different terms and conditions, which may include waiting periods for pre-
existing conditions."
C. "You can sue the insurance carrier for federal fraud because pre-existing condition bans are
universally illegal."
D. "Your hospital case manager can override the private insurance policy rules by executive
decree."
CORRECT ANSWER : B
Rationale: Health insurance plans purchased outside the official Health Insurance Market
Exchange established under the ACA do not necessarily adhere to all ACA consumer
protections, meaning they may retain waiting periods or exclusions for pre-existing conditions.
6. A case manager is evaluating a frail older adult client to determine functional independence
levels. Which three core domains comprise a comprehensive functional status assessment?
, A. Blood pressure, heart rate, and temperature trends.
B. Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), and
Mobility (fall risk).
C. Occupational history, credit score, and marital status.
D. Genomic sequencing, viral titers, and metabolic panels.
CORRECT ANSWER : B
Rationale: A functional status assessment evaluates a patient's self-care abilities via Activities of
Daily Living (ADLs), complex independent living tasks via Instrumental Activities of Daily
Living (IADLs), and physical stability through mobility and fall risk screens.
7. A case manager is utilizing aggregated diagnosis groups (ADGs) to classify a patient's health
status and resource utilization profile. In which primary category would an acute localized skin
infection be classified?
A. Surgical intervention complexity index
B. Disease etiology and clinical manifestation category
C. Financial billing reimbursement tier
D. Hospital readmission penalty matrix
CORRECT ANSWER : B
Rationale: Aggregated Diagnosis Groups (ADGs) categorize patient disease profiles based on
disease etiology and expected clinical severity to predict healthcare utilization and resource
needs.
8. A clinically stable patient requires continuous intravenous infusion therapy upon discharge
home. In preparing the care transition plan, what is the most appropriate care delivery workflow
for the case manager to implement?
A. Discontinue all intravenous lines and instruct the patient to take oral fluids exclusively.
B. Ensure a PICC line or central venous access is placed prior to discharge, then
coordinate care with an accredited ambulatory infusion care center or home health nursing
agency.
C. Send the patient home without vascular access and expect emergency room staff to manage
daily infusions.
