The cookie settings on this website are set to 'allow all cookies' to give you the very best experience. Please click Accept Cookies to continue to use the site.

Test Bank For Foundations of Psychiatric Mental Health Nursing- A Clinical Approach, 5th Edition by Elizabeth M. Varcarolis Test Bank

$55.00 $45.00
(You save $10.00)
(No reviews yet) Write a Review
SKU:
Test Bank For Foundations of Psychiatric Mental Health Nursing- A Clinical Approach, 5th Edition by Elizabeth M. Varcarolis Test Bank

Test Bank For Foundations of Psychiatric Mental Health Nursing- A Clinical Approach, 5th Edition by Elizabeth M. Varcarolis Test Bank

 

INSTANT DOWNLOAD

What student Can You Expect From A Test Bank?

A test bank will include the following questions:

 

Description

Foundations of Psychiatric Mental Health Nursing- A Clinical Approach, 5th Edition by Elizabeth M. Varcarolis Test Bank

Varcarolis: Foundations of Psychiatric Mental Health Nursing: A

Clinical Approach, 5th Edition

 

Test Bank

 

Chapter 6: Mental Health Nursing in Community Settings

 

MULTIPLE CHOICE

 

1)   Nurse A works in an inpatient unit in the community mental health center. Nurse B is a community mental health nurse. To provide comprehensive care to clients, which skill must nurse B use that nurse A does not currently use?

A. A calm external manner
B. Problem-solving skills
C. Ability to cross service systems
D. Knowledge of psychopharmacology

 

ANS:   C

A community mental health nurse must be able to work with schools, corrections facilities, shelters, health care providers, and employers. The mental health nurse working in an inpatient unit needs only to be able to work within the single setting. Option A: This manner would be needed by nurses in both settings. Option B: Problem-solving skills are needed by all nurses. Option D: Nurses in both settings must have knowledge of psychopharmacology.

 

DIF:     Cognitive Level: Analysis                 REF:    Text Page: 89

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment;

 

 

2)   The community mental health nurse calls on a highly suspicious psychiatric client, saying “I’m a nurse from the mental health center. I’d like to come in and find out how you’re doing.” The client refuses to allow the nurse access to her apartment, saying “My neighbor talks to me every day. I don’t know you. You could be from the IRS or the CIA. The less you know about me, the better.” The best initial intervention for the nurse to take to try to gain access would be to

A. ask the client’s neighbor to go with her.
B. have the police accompany her.
C. deny a relationship with the IRS or CIA.
D. mention the client will have to go to the hospital unless she sees the nurse.

 

ANS:   A

 

Having a person the client trusts intercede on the nurse’s behalf may smooth the way for the nurse and client to develop a trusting relationship. Option B: This measure would be a last resort. Option C: This would be ineffective because of the client’s high level of suspicion. Option D: This is a threat that could be construed as an assault.

 

DIF:     Cognitive Level: Application            REF:    Text Page: 86, Text Page: 87

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment;

 

 

3)   A desirable treatment outcome for a seriously mentally ill client in an inpatient setting might be that “The client will show stabilization of symptoms and return to the community.” In contrast, an identified outcome for a seriously mentally ill client being treated in a community setting should be that “The client will demonstrate

A. the ability to maintain stability in the community.”
B. an absence of symptoms and improved level of functioning.”
C. functioning at a moderate to high level of social integration.”
D. socially acceptable interactions within the community, good self-care, and adequate nutrition.”

 

ANS:   A

Symptoms often worsen when the client is discharged from the hospital and no longer has the support and structure of the hospital setting. The client can remain in the community if he or she can cope with the symptoms and situational demands (i.e., maintain stability). The goals listed in the other options are unrealistically high.

 

DIF:     Cognitive Level: Application            REF:    Text Page: 88

TOP:   Nursing Process: Planning (Outcome Identification)

MSC:  NCLEX: Psychosocial Integrity

 

 

4)   Which intervention strategy would the community psychiatric nurse include when planning care for a mentally ill client being cared for in the community?

A. Enforce boundaries by way of seclusion.
B. Develop a long-term relationship.
C. Administer prescribed medication three times daily.
D. Provide three nutritious meals with snacks between meals.

 

ANS:   B

A long-term relationship is necessary to care for clients in the community because the time span of care is lengthy. Because hospitalizations are currently so brief, establishing a short-term relationship is all that can be expected. Options A, C, and D are interventions that would occur in the hospital rather than in the community.

 

DIF:     Cognitive Level: Application            REF:    Text Page: 88

TOP:   Nursing Process: Planning                MSC:   NCLEX: Psychosocial Integrity

 

 

5)   A client states “I don’t understand all these levels of nurses.” Which reply provides the client with accurate information? “In contrast to the role of the psychiatric nurse prepared to provide basic and direct nursing care, the advanced practice psychiatric mental health nurse is exclusively able to

A. provide mental health care if under the direct supervision of a physician.”
B. contract to provide mental health services for individuals or groups.”
C. participate in research projects if protocols have been approved by senior researchers.”
D. assist with medication management but not actually prescribe it.”

 

ANS:   B

The only exclusive role of the advanced practice nurse mentioned in the options is contracting to provide mental services to individuals or groups. Options A, C, and D are functions the nurse with basic preparation can perform.

 

DIF:     Cognitive Level: Application            REF:    Text Page: 88

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment;

 

 

6)   The community psychiatric nurse learns that a suspicious and socially isolated client who lives alone chooses to eat one meal a day at a nearby soup kitchen and spend the remainder of his daily food allowance on cigarettes. The nurse’s initial action should be to

A. tell the client he must stop smoking to save money.
B. assess weight and determine foods and amounts eaten.
C. report the situation to the manager of the soup kitchen.
D. seek rehospitalization for the client while a new plan is put into place.

 

ANS:   B

Assessment of biopsychosocial needs and general ability to live in the community is called for before any action is taken. Both nutritional status and income adequacy are critical assessment parameters. Option A: This demand would probably be ignored. Remember, a client may be able to maintain adequate nutrition while eating only one meal a day. Option C: The rule is to assess before taking action. Option D: Hospitalization may not be necessary.

 

DIF:     Cognitive Level: Application            REF:    Text Page: 87, Text Page: 88

TOP:   Nursing Process: Assessment           MSC:   NCLEX: Physiologic Integrity

 

 

7)   The community psychiatric nurse notes that a client with schizophrenia has remained stable in the community for 6 weeks after discharge from the hospital. Two weeks after making this notation in the medical record, the nurse is called by the client’s husband to say that the client is delusional and explosive. During the home visit the nurse learns that the client is willing to take medication, but when her 90-day supply ran out she had none to take. The nurse arranges for a prescription refill. To avoid recurrence of this situation

A. the nurse will obtain the prescription refill every 90 days and deliver it to the client.
B. the client’s husband will mark dates to obtain prescription refills on the calendar.
C. the client will report to the hospital for medication follow-up every week.
D. the client will call the nurse weekly to discuss medication-related issues.

 

ANS:   B

The nurse will attempt to use the client’s support system to meet client needs whenever possible. Option A should be unnecessary for the nurse to do if client or a significant other can be responsible. Option C: The client may not need more intensive follow-up as long as she continues to take medication as prescribed. Option D: This is probably unnecessary because no client issues except failure to obtain medication refill were identified.

 

DIF:     Cognitive Level: Application            REF:    Text Page: 88

TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment;

 

 

8)   The nurse assigned to an assertive community treatment program should explain the program’s treatment goals as

A. assisting clients to maintain abstinence from alcohol and other substances of abuse.
B. maintaining medications and stable psychiatric status for incarcerated inmates who have a history of mental illness.
C. providing assessment and intervention for mentally ill individuals who would otherwise have no access to care.
D. providing structure and a therapeutic milieu for mentally ill clients whose symptoms require stabilization.

 

ANS:   C

A mobile health care unit cares for individuals who would not come to a treatment facility or an established site. Assessment and intervention are the primary aspects of the nursing process used. Little time for extensive planning and little opportunity for evaluation of outcomes exist. Option A is a goal relevant to a substance abuse treatment program. Option B is a goal relevant to a forensic setting. Option D is a goal of an inpatient unit.

 

DIF:     Cognitive Level: Application

REF:    Text Page: 92, Text Page: 93, Text Page: 94

TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment;

 

 

9)   The nurse assigned to the assertive community treatment program is responsible for determining the location of a new inner city site for a 3-hour block of time each Tuesday. The nurse has learned the following facts: A conference room is available on the sixth floor of city hall as well as a large lobby area on the first floor, either of which could each be used as a site between 9 AM and noon. City police have been successful in clearing homeless individuals from a two-block area around city hall. A firehouse near city hall has offered a room that could be used on alternate Tuesdays from 2 to 5 PM. A fast-food restaurant located approximately four blocks from city hall is willing to allow use of its “party room” from 7 to 10 AM. The most preferable site would be the

A. city hall conference room.
B. city hall lobby.
C. firehouse room.
D. restaurant “party room.”

 

ANS:   D

The room in the fast-food restaurant is preferable because it could be used consistently each week and because inner city residents, including those from the homeless shelter, could go there without interference.

 

DIF:     Cognitive Level: Analysis

REF:    Text Page: 92, Text Page: 93, Text Page: 94

TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment;

 

 

10)   A community mental health nurse has been working for 6 months to establish a trusting relationship with a delusional and suspicious client. The client recently lost his job, stopped taking medication because he had no money, and then decompensated. The client states “only a traitor would make me go to the hospital.” The nurse must decide whether to arrange for hospitalization or try to provide medication so he can remain at home. The solution most in keeping with current practices in health care calls for

A. hospitalization for up to a week.
B. negotiating a way to provide medication.
C. hospitalization until he is asymptomatic.
D. arranging for a bed in a homeless shelter.

 

ANS:   B

Although no absolutely “right” answer exists, hospitalization will damage the nurse-client relationship even if it provides an opportunity for rapid stabilization. If medication can be obtained and restarted, the client can possibly be stabilized in the home setting, even if it takes a little longer. Option D: A homeless shelter is inappropriate and unnecessary.

 

DIF:     Cognitive Level: Analysis                 REF:    Text Page: 86

TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment;

 

 

11)   An activity a nurse engaged exclusively in community-based primary prevention would implement is

A. substance abuse counseling.
B. teaching parenting skills.
C. medication follow-up.
D. depression screening.

 

ANS:   B

Primary prevention activities are directed to healthy populations to provide information for developing skills that will result in preventing mental illness. The other options are secondary prevention activities.

 

DIF:     Cognitive Level: Application            REF:    Text Page: 86

TOP:   Nursing Process: Implementation     MSC:   NCLEX: Psychosocial Integrity

 

 

12)   A Vietnamese immigrant is a student at the local community college nursing program. The nursing instructor is concerned because the student has poor eye contact and has difficulty asking the direct questions necessary for client assessment. The nursing instructor arranges for the student to be assessed by the nurse practitioner in the college health service. This action reflects

A. appropriate secondary prevention by the instructor.
B. insufficient understanding of the student’s culture.
C. a violation of the student’s civil rights.
D. prejudice and discrimination.

 

ANS:   B

In the student’s culture making eye contact can be perceived as disrespectful. In addition, asking direct questions may seem to the student to be intrusive and disrespectful. Option A: This behavior is not symptomatic of psychiatric illness; thus referral is inappropriate. Option C: Referral does not violate civil rights, although it is insensitive on the part of the nursing instructor. Option D: No evidence exists that the instructor was prejudiced rather than uninformed.

 

DIF:     Cognitive Level: Analysis                 REF:    Text Page: 87, Text Page: 88

TOP:   Nursing Process: Implementation     MSC:   NCLEX: Psychosocial Integrity

 

 

13)   A client who has serious and persistent symptoms of schizophrenia lives in the community. On a home visit, the community psychiatric nurse case manager learns that the client:

  • Will begin attending an activities group at the mental health outreach center
  • Is worried that he may not have enough money to pay for the therapy
  • Does not know how to get from home to the outreach center
  • Has an appointment to have blood work at the same time the activities group meets

The task listed below that is outside the coordinating role of the nurse would be

A. negotiating the cost of therapy for the client.
B. rearranging conflicting care appointments.
C. arranging transportation to the outreach center.
D. monitoring to ensure that client needs are met.

 

ANS:   A

The actions mentioned in options B, C, and D reflect the coordinating role of the community psychiatric nurse case manager. Negotiating the cost of therapy is an intervention the nurse would not be expected to undertake.

 

DIF:     Cognitive Level: Application            REF:    Text Page: 89

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment;

 

 

14)   The assessment data item more relevant for the community psychiatric health nurse than the hospital-based psychiatric nurse for planning client interventions is

A. history of mental illness in the family.
B. culturally related psychotropic dosing.
C. financial status of the client.
D. physical state of the client.

 

ANS:   C

The financial status of the client determines the viability of certain interventions in the community but is of little or no concern when determining a program of in-hospital treatment. The family history of mental illness, the physical status of the client, and culturally related dosage differences for psychotropic drugs would be of equal concern to the nurse in the hospital and the nurse in the community.

 

DIF:     Cognitive Level: Application            REF:    Text Page: 87, Text Page: 88

TOP:   Nursing Process: Planning                MSC:   NCLEX: Psychosocial Integrity

 

 

15)   The community psychiatric nurse is attempting to facilitate medication compliance for a client by having the physician prescribe depot medication that will be given by injection every 3 weeks at the community mental health outreach clinic. For this plan to be successful, what factor will the nurse assess as being of critical importance?

A. The attitude of significant others toward the client
B. Nutrition services in the client’s neighborhood
C. A trusting relationship between the client and the nurse
D. The availability of transportation to the clinic

 

ANS:   D

The ability of the client to get to the clinic is of paramount importance to the success of the plan. The depot medication relieves the client of the necessity to take medication daily, but if he or she does not receive the injection at 3-week intervals, noncompliance will again be the issue. Options A, B, and C: Attitude toward the client, trusting relationships, and nutrition are important but not fundamental to this particular problem.

 

DIF:     Cognitive Level: Analysis                 REF:    Text Page: 86, Text Page: 87

TOP:   Nursing Process: Assessment

MSC:  NCLEX: Safe, Effective Care Environment;

 

 

16)   The community psychiatric nurse makes a home visit to see a client who is scheduled to receive home care. The nurse notes the client and family make poor eye contact and that the client and all members of the family deferred to the father to answer questions during the visit. In what sphere does the explanation for this observation probably reside?

A. Physical
B. Cultural
C. Environmental
D. Psychopathological

 

ANS:   B

Eye contact and family patterns of authority are often culturally determined. The other options are much less likely to provide a plausible explanation of the observation. Option A: All parties are physically able to communicate. Option C: The environment is identical for all possible speakers. Option D: No mention of psychopathology for any family members is given.

 

DIF:     Cognitive Level: Application            REF:    Text Page: 87, Text Page: 88

TOP:   Nursing Process: Assessment           MSC:   NCLEX: Psychosocial Integrity

 

 

17)   Outcomes established with the mentally ill client in the community compared with those planned for a hospitalized client will

A. involve a longer time frame.
B. require more psychoeducation.
C. have greater focus on symptom absence.
D. be more concerned with medication management.

 

ANS:   A

Community care is concerned with long-term outcomes, whereas hospital care is concerned with short-term outcomes. Options B and D: Planning in either setting would be equally concerned with medication management and necessary psychoeducation. Option C: Planning in either setting would probably not set goals for absence of symptoms, which might be unrealistic.

 

DIF:     Cognitive Level: Analysis                 REF:    Text Page: 88

TOP:   Nursing Process: Planning                MSC:   NCLEX: Psychosocial Integrity

 

 

18)   Nurse extenders in the hospital are called psychiatric technicians or nursing assistants. Whom should the nurse identify as extenders in community psychiatric care?

A. Pharmacists
B. Social workers
C. Psychiatrists and psychologists
D. Supportive or concerned acquaintances

 

ANS:   D

Nurses in the community are often assisted by informal helpers such as the significant others of the client, the landlord, the local police, clergy, and other concerned volunteers. Community-based nurses and clients have less contact with the traditional members of the interdisciplinary team than do individuals in the hospital-based setting.

 

DIF:     Cognitive Level: Comprehension     REF:    Text Page: 88

TOP:   Nursing Process: Assessment

MSC:  NCLEX: Safe, Effective Care Environment;

 

 

19)   The client assessment finding that deserves priority intervention by the nurse working in the community setting is that the client

A. receives Social Security disability income plus a small check from a trust fund.
B. lives in an apartment with two clients who attend day hospital programs.
C. has a sister who is interested and active in his care planning.
D. purchases and uses marijuana on a frequent basis.

 

ANS:   D

Clients who regularly buy illegal substances often become medication noncompliant. Medication noncompliance, along with the disorganizing influence of illegal drugs on cellular brain function, promotes relapse. Options A, B, and C do not suggest problems.

 

DIF:     Cognitive Level: Analysis                 REF:    Text Page: 86, Text Page: 87

TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment;

 

 

20)   A client tells the nurse at the medication management clinic that she hasn’t taken her antidepressant medication as the physician directed; she “forgets” the midday dose because she has lunch with friends and doesn’t want to be different because she takes pills. The most appropriate intervention for the nurse would be to

A. investigate the possibility of once-daily dosing.
B. explain how taking each dose of medication on time relates to health maintenance.
C. suggest she confide in a co-worker and ask if the co-worker would also take some sort of medication at noon.
D. establish the nursing diagnosis of “noncompliance with medication regimen related to lack of knowledge” on the care plan.

 

ANS:   A

Option A has the highest potential for helping the client achieve compliance. Many antidepressants can be administered by once-daily dosing, a plan that increases compliance. Option B is reasonable but would not achieve the goal because it does not address the issue of stigma. Option C: The self-conscious client would not be comfortable doing this. Option D: A better etiology statement would be related to social stigma.

 

DIF:     Cognitive Level: Analysis                 REF:    Text Page: 89

TOP:   Nursing Process: Implementation     MSC:   NCLEX: Psychosocial Integrity

 

 

21)   The community psychiatric nurse makes the assessment that, based on biological signs, a seriously and persistently mentally ill client with a mood disorder seems to be somewhat more depressed than on his previous clinic visit a month ago. The client, however, states he feels the same. The intervention that gives credence to the nurse’s assessment while supporting client autonomy is to

A. arrange for a short hospitalization.
B. schedule weekly clinic appointments.
C. refer to the crisis intervention clinic.
D. call the client’s family and ask them to observe the client closely.

 

ANS:   B

Scheduling clinic appointments at shorter intervals will give the opportunity for more frequent assessment of symptoms and allow the nurse to use early intervention. Option A is wasteful of scarce resources. Option C: If the client does not admit to having a crisis or problem this referral would be useless. Option D: This may or may not produce reliable information.

 

DIF:     Cognitive Level: Analysis                 REF:    Text Page: 89

TOP:   Nursing Process: Implementation     MSC:   NCLEX: Psychosocial Integrity

 

 

22)   A client with serious mental illness lives alone in a neighborhood in which she is well accepted as someone who can baby-sit for an hour or two or who will help with housekeeping chores if someone is ill. The client receives depot medication injections but lately has missed regular clinic appointments, saying “My life is so busy I couldn’t find time to come in.” To prevent hospitalization associated with noncompliance with medication regimen, the community mental health nurse should arrange for

A. psychosocial club membership.
B. assertive community treatment.
C. an appointment with a nurse in private practice.
D. health maintenance organization authorization for changing to daily oral medication.

 

ANS:   B

The assertive community treatment team could bring the client’s medication to her in her neighborhood. Option D: Depot medication is a strategy to reduce noncompliance and is often preferable to daily oral medication. Options A and C do not directly relate to the noncompliance problem.

 

DIF:     Cognitive Level: Application

REF:    Text Page: 92, Text Page: 93, Text Page: 94

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment;

 

 

23)   In a rush of words, a client tells the community mental health nurse “Everything’s a mess! I can’t concentrate. My disability check didn’t come. My roommate moved out and the rent is too much for me to pay on my own. To top it all off, my therapist is moving out of state. I don’t know where to turn and I feel as though I’m coming apart at the seams.” A nursing diagnosis the nurse should consider for this client is

A. decisional conflict related to challenges to personal values.
B. spiritual distress related to ethical implications of treatment regimen.
C. anxiety related to changes perceived as threatening to psychological equilibrium.
D. deficient knowledge related to need to solve multiple problems affecting security needs.

 

ANS:   C

Subjective and objective data obtained by the nurse suggest the client is experiencing anxiety caused by multiple threats to security needs. Option A: Data are not present to suggest decisional conflict, ethical conflicts around treatment causing spiritual distress, or deficient knowledge.

 

DIF:     Cognitive Level: Analysis                 REF:    Text Page: 87, Text Page: 88

TOP:   Nursing Process: Nursing Diagnosis

MSC:  NCLEX: Psychosocial Integrity

 

 

24)   The client that a nurse would plan to refer to a partial hospitalization program is the individual who

A. spent yesterday in the 24-hour supervised crisis care center and continues to be actively suicidal.
B. has agoraphobia and panic episodes and needs psychoeducation for relaxation therapy.
C. is well regulated on lithium and reports regularly for blood tests and clinic follow-up.
D. is being discharged from an alcohol detoxification unit. He states, “I’m not sure I can abstain after my wife goes to work in the morning.”

 

ANS:   D

This client could profit from the structure and supervision provided by spending the day at the partial hospitalization program. During the evening, at night, and on weekends his wife could assume responsibility for supervision. Option A: This client would need hospitalization. Option B: This client could be referred to home care. Option C: This client could continue on the same plan.

 

DIF:     Cognitive Level: Analysis                 REF:    Text Page: 90

TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment;

 

 

25)   For the client to be discharged from acute hospital care to clinical case management at home, care planning should be predicated on evidence that best outcomes will be produced by

A. weekly follow-up for 6 weeks, then every 2 weeks.
B. monthly follow-up for 6 months to 1 year.
C. no follow-up for 3 months, then quarterly visits.
D. referral to the assertive treatment team for daily contact.

 

ANS:   A

Best outcomes are achieved when clients have regular, frequent follow-up in the community. Options B and C provide too little follow-up. Option D provides a more intensive follow-up than may be required.

 

DIF:     Cognitive Level: Analysis                 REF:    Text Page: 90

TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment;

 

 

OTHER

 

1)   A nurse can best address factors of critical importance to successful community treatment during a new client interview by including assessments relative to (more than one answer may be correct)

  1. housing adequacy and stability.
  2. income adequacy and stability.
  3. family and other support systems.
  4. early psychosocial development.
  5. substance abuse history and current use.

 

ANS:

A, B, C, E

Rationale: Early psychosocial developmental history is less relevant to successful outcomes in the community than the assessments listed in the other options. If a client is homeless or fears homelessness, focusing on other treatment issues is impossible. Option B: Sufficient income for basic needs and medication is necessary. Option C: Adequate support is a requisite to community placement. Option D: This information has less bearing on the success of community treatment than the issues related to daily living arrangements. Option E: Substance abuse undermines medication effectiveness and interferes with community adjustment.

 

DIF:     Cognitive Level: Application            REF:    Text Page: 87, Text Page: 88

TOP:   Nursing Process: Assessment           MSC:   NCLEX: Psychosocial Integrity

 

 

2)   The client statements that identify aspects of nursing functions of high therapeutic value to a client being followed by an interdisciplinary community mental health team are “The nurse (more than one answer may be correct)

  1. talks in language I can understand.”
  2. looks at me as a whole person with lots of needs.”
  3. lets me do whatever I choose without interfering.”
  4. helps me keep track of my medication.”
  5. is willing to go on a date with me.”

 

ANS:

A, B, D

Rationale: Each of the correct answers is an example of appropriate nursing foci: communicating at a level understandable to the client, using holistic principles to guide care, and providing medication supervision. Option C suggests a laissez faire attitude on the part of the nurse, when the nurse should provide thoughtful feedback and help clients test alternative solutions. Option E is a boundary violation.

 

DIF:     Cognitive Level: Analysis                 REF:    Text Page: 88, Text Page: 89

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment;