A burn victim's immunization history is assessed by the nurse. Which immunization is of priority concern?
Answer(s): C
(A) Oral poliovirus vaccine is given to prevent polio. Polio is transmitted by direct contact with an infected person. (B) Inactivated poliovirus vaccine is given to adults and immunosuppressed individuals. Polio is transmitted by direct contact with an infected person. (C) Tetanus toxoid prevents tetanus. Tetanus is transmitted through contaminated wounds. (D) Hepatitis B vaccine prevents hepatitis B infection. Hepatitis B is transmitted through contact with infected blood or body fluids.
A schizophrenic client who is experiencing thoughts of having special powers states that "I am a messenger from another planet and can rule the earth." The nurse assesses this behavior as:
Answer(s): D
(A) Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. (B) Clients experiencing delusions of persecution believe that others in the environment are plotting against them. (C) Clients experiencing thought broadcasting perceive that others can hear their thoughts. (D) Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers.
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