A nurse in a community health center is assessing the results of a tuberculin skin test she performed on a client. Which of the following results indicates exposure to and a possible infection with tuberculosis (TB)?
10 mm wheal
5 mm induration
15 mm induration
4 mm erythema
The Correct Answer is C
Choice A Reason:
A 10 mm wheal is not indicative of TB infection. A wheal is a raised, often itchy area of skin that usually signifies an allergic reaction, not an infection. The TST looks for induration, which is a firm swelling, as a sign of TB infection.
Choice B Reason:
A 5 mm induration is considered positive in certain high-risk groups, such as people living with HIV, recent contacts of TB patients, or those with a history of organ transplants. For individuals without these risk factors, a 5 mm induration is not considered a positive result.
Choice C Reason:
A 15 mm induration is considered a positive TST result for individuals with no known risk factors for TB. This indicates that the person's immune system has reacted to the tuberculin purified protein derivative (PPD) injected under the skin, suggesting exposure to TB bacteria.
Choice D Reason:
Erythema, or redness of the skin, is not measured when interpreting TST results. The test measures induration, which is a palpable, raised, hardened area or swelling. Therefore, a 4 mm erythema does not indicate TB infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A reason:
Raisins are dried grapes and are known to have a higher concentration of nutrients, including potassium. For individuals with chronic kidney disease (CKD), consuming foods like raisins that are high in potassium can lead to hyperkalemia, a condition where potassium levels in the blood are higher than normal. This can be dangerous as it may cause heart rhythm problems.
Choice B reason:
Asparagus is considered a lower-potassium food, making it a safer choice for people with CKD. It's important for individuals with CKD to manage their potassium intake, but asparagus can be included in their diet in appropriate portions.
Choice C reason:
Bananas are well-known for being rich in potassium. For someone with CKD, eating bananas can contribute to an excessive intake of potassium, which their kidneys may not be able to eliminate efficiently, potentially leading to hyperkalemia.
Choice D reason:
Tomatoes, including tomato products like sauces, juices, and purees, are high in potassium. Therefore, they should be limited or avoided in the diet of a person with CKD to prevent complications associated with high potassium levels.
Choice E reason:
Green beans are considered to be a lower-potassium vegetable. They can be included in a kidney-friendly diet, provided they are consumed in moderation and balanced with other dietary needs.
Correct Answer is C
Explanation
Choice A reason:
Kernig's sign is associated with meningitis and is not related to the symptoms of tingling sensations that can occur after a subtotal thyroidectomy. This sign is elicited by extending the client's leg at the knee while the hip is flexed, which would not be relevant in this case.
Choice B reason:
Brudzinski's sign is another indicator of meningitis and involves involuntary flexion of the hips and knees when attempting to flex the client's neck. Similar to Kernig's sign, it is not pertinent to the postoperative symptoms of a subtotal thyroidectomy.
Choice C reason:
Chvostek's sign is a clinical sign of existing neuromuscular irritability seen in hypocalcemia, which can occur after thyroid surgery due to accidental removal or damage to the parathyroid glands. Tapping on the facial nerve triggers twitching of the facial muscles, which correlates with the tingling sensations reported by the client.
Choice D reason:
Babinski's sign is used to assess neurological function, particularly of the central nervous system, and is not related to the symptoms of hypocalcemia. It involves stroking the sole of the foot to observe the toes' movements, which would not provide information about the tingling sensations the client is experiencing.
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