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 A

Explanation

Choice A reason:
A reddened area over the sacrum is a sign of potential pressure ulcer development, which is a common complication of immobility, especially in bedridden or wheelchair-bound individuals. The sacrum is a prominent bony area that bears weight when a person is sitting or lying down, making it susceptible to pressure ulcers if proper preventative measures, such as regular repositioning, are not taken.

Choice B reason:
Difficulty hearing some types of sounds is not typically a direct complication of immobility. Hearing issues may be related to other health conditions or age-related changes but are not caused by the lack of movement associated with post-stroke immobility.

Choice C reason:
Stiffness in the lower extremities can occur due to immobility, as muscles and joints may become tight when not used regularly. However, this is more of a long-term effect and may not be as immediately concerning as pressure ulcer prevention. Regular range-of-motion exercises can help prevent stiffness.

Choice D reason:
Difficulty moving the upper extremities may be a result of the stroke itself rather than a complication of immobility. While maintaining mobility in all limbs is important, the focus of monitoring should be on complications that arise specifically due to immobility, such as pressure ulcers.

A. The lesions are contagious to others only if they are draining. B. Vesicles will appear followed by pain and/or itching. C. Many clients experience pain in the affected area for weeks after the lesions have resolved. D. Herpes zoster is easily spread to family and friends who have had chickenpox in the past.

Correct Answer is ["A","B","C"]

Explanation

Choice A reason:
Herpes zoster lesions are indeed contagious if they are draining. The virus can spread through direct contact with the fluid from the blisters. It is crucial to cover the lesions to prevent spreading the virus to others, especially to those who have never had chickenpox or the vaccine.

Choice B reason:
The development of vesicles, which are small fluid-filled blisters, is a hallmark of herpes zoster. These vesicles typically appear in a band-like pattern on one side of the body and are often accompanied by pain, itching, or tingling before they are visible.

Choice C reason:
Postherpetic neuralgia is a condition where the pain persists in the area of the herpes zoster rash even after the lesions have healed. This can last for weeks, months, or even years and is more common in older adults.

Choice D reason:
Herpes zoster itself is not spread like chickenpox. It occurs when the varicella-zoster virus, which has been lying dormant in the nerve cells, reactivates. While it is possible for someone who has never had chickenpox to develop chickenpox after direct contact with a shingles rash, herpes zoster is not "easily spread" to others in the same way that chickenpox is.

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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 in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and is unable to move independently. The nurse should monitor for which of the following complications of immobility?

Correct Answer is A

Explanation

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Correct Answer is ["A","B","C"]

Explanation

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