A nurse is working with a client diagnosed with complex somatic symptom disorder. Which of the following would the nurse identify as the most difficult aspect of providing care to this client?

Correct Answer: C

Rationale: The correct answer is C: Developing the therapeutic relationship. In complex somatic symptom disorder, patients often have difficulty trusting healthcare providers and may resist treatment. Developing a therapeutic relationship requires patience, empathy, and understanding. It is crucial for effective care as it allows the nurse to address the underlying psychological issues contributing to the somatic symptoms. Pain management (choice A) and anxiety relief (choice B) are important but may be more straightforward compared to building trust and rapport. Monitoring treatment (choice D) is essential but can be done effectively once a therapeutic relationship is established.

Correct Answer: A

Rationale: The correct answer is A: Risk for falls R/T right-sided weakness and sedation from risperidone. This is the priority nursing diagnosis because the client's physical aggression and right-sided weakness increase the risk of falls, which can lead to further injury. The sedative effect of risperidone can further impair the client's balance and coordination, exacerbating the risk. Addressing this risk is crucial to ensure the safety and well-being of the client. Summary of other choices: B: Activity intolerance R/T right-sided weakness - While this is a relevant concern, it is not the priority as the risk of falls takes precedence. C: Disturbed thought processes R/T acting-out behaviors - While the client's behavior may be a concern, addressing the immediate risk of falls is more critical. D: Anxiety R/T change in health status and dependence on others - While anxiety may be present, addressing the risk of falls is more urgent in this situation.

Correct Answer: A

Rationale: The correct answer is A: Lithium (Eskalith). Lithium is known to cause fluid and electrolyte imbalances by affecting sodium and water reabsorption in the kidneys. Patients on lithium therapy should be closely monitored for signs of dehydration, hyponatremia, and other electrolyte disturbances. Clozapine, Diazepam, and Amitriptyline do not typically cause significant fluid and electrolyte imbalances. Monitoring is still important, but not as critical as with lithium.

Correct Answer: C

Rationale: The correct answer is C because the nurse is assessing immediate and short-term memory. Giving the patient three words to recite now and then in 5 minutes tests both immediate recall and short-term memory retention. This task assesses the patient's ability to retain information over a brief period, which is crucial for evaluating memory function. In contrast, options A, B, and D involve different memory processes or timeframes and are not as directly relevant to assessing immediate and short-term memory. Option A focuses on long-term memory, option B involves problem-solving skills, and option D primarily tests orientation rather than memory retention.

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Completing a mental status exam is crucial in assessing behavioral health clients. 2. Failing to do so may result in missing important information about the client's mental state. 3. DeShawna's statement indicates a lack of understanding of the importance of a mental status exam. 4. This demonstrates her need for assistance in recognizing the significance of thorough assessments. Summary of Incorrect Choices: A: Completing all parts of the nursing assessment is positive but does not specifically address the need for a mental status exam. C: Gathering medication names is important but does not address the need for a mental status exam. D: Assessing for suicidal ideation is crucial, but it does not address the need for a mental status exam, which is also essential in behavioral health assessments.