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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason:
While the white blood cell (WBC) count is important in assessing the immune system's ability to fight infection, a WBC of 5,000/mm³ is within the normal range (4,500 to 11,000 WBCs/mm³). Therefore, it is not the most critical value for a nurse to prioritize in the care of an HIV patient.

Choice B reason:
A platelet count of 150,000/mm³ is also within the normal range (150,000 to 450,000 platelets/mm³). Although thrombocytopenia can occur in HIV, this value does not indicate an immediate concern for the nurse to prioritize.

Choice C reason:
A positive Western blot test confirms the presence of HIV antibodies, which is indicative of HIV infection. However, this is a diagnostic result rather than a laboratory value that reflects the current status of the patient's immune function or disease progression.

Choice D reason:
The CD4-T-cell count is a critical laboratory value for assessing the immune function of a patient with HIV. A count of 180 cells/mm³ is below the normal range of 500 to 1,200 cells/mm³ and indicates a significantly weakened immune system, placing the patient at risk for opportunistic infections. This value is a priority as it guides treatment decisions and the need for prophylaxis against opportunistic infections.

A. Gingivitis B. Xerostomia C. Candidiasis D. Halitosis

Correct Answer is C

Explanation

Choice A reason:
Gingivitis, an inflammation of the gums, is not specifically associated with a decreased CD4+ T-cell count. While individuals with HIV/AIDS may have an increased risk for periodontal diseases due to a compromised immune system, gingivitis is not directly linked to the CD4+ T-cell count¹.

Choice B reason:
Xerostomia, or dry mouth, can be a side effect of medications or secondary to other conditions but is not an infectious condition. It is not directly related to a decreased CD4+ T-cell count, although it may be more common in individuals with HIV/AIDS due to various factors, including medication side effects¹.

Choice C reason:
Candidiasis, also known as oral thrush, is a common opportunistic infection in individuals with HIV/AIDS, especially when the CD4+ T-cell count is significantly decreased. It is caused by the fungus Candida and can lead to white patches in the mouth, soreness, and difficulty swallowing.

Choice D reason:
Halitosis, or bad breath, is not an infectious condition and is not directly associated with a decreased CD4+ T-cell count. It can result from various factors, including oral hygiene, diet, or underlying health conditions, but it is not a specific concern related to HIV/AID.

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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