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Question 1 of 5

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:

Correct Answer: D

Rationale: Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. Clients experiencing delusions of persecution believe that others in the environment are plotting against them. Clients experiencing thought broadcasting perceive that others can hear their thoughts. Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers.

Question 2 of 5

A terrorist attack has left hundreds of patients with injuries determined to be in the immediate category as defined by NATO. The color to designate this group is:

Correct Answer: C

Rationale: In NATO triage the immediate category (requiring urgent intervention to survive) is designated by red. Black indicates deceased or expectant yellow is delayed and green is minimal.

Question 3 of 5

The nurse is caring for a client with a history of ectopic pregnancy. Which risk factor is most likely to be present?

Correct Answer: A

Rationale: Pelvic inflammatory disease (PI
D) is a major risk factor for ectopic pregnancy as it can scar the fallopian tubes impairing embryo transport. Gestational diabetes hypertension and multiple gestations are not strongly associated.

Question 4 of 5

Which of the following is the best indicator of the diagnosis of HIV?

Correct Answer: C

Rationale: The Western blot is the confirmatory test for HIV diagnosis, detecting specific antibodies with high specificity. ELISA is a screening test, while WBC and CBC are non-specific and not diagnostic for HIV.

Question 5 of 5

A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:

Correct Answer: C

Rationale: Ampicillin is a safe antibiotic for pyelonephritis in pregnancy, with no known teratogenic effects.

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