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 B
Explanation
Choice A reason:
The statement "This procedure is routinely performed during a Pap test" is incorrect. A colposcopy is not routinely performed during a Pap test; it is a separate procedure that is often recommended if a Pap test shows abnormal results. The colposcopy allows for a closer examination of the cervix, vagina, and vulva to detect any signs of disease.
Choice B reason:
The statement "During the procedure, a biopsy may be performed" is correct. If the healthcare provider sees an area of concern during the colposcopy, they may take a small sample of tissue (biopsy) from the cervix or from inside the opening of the cervix.
Choice C reason:
The statement "Do not eat or drink after midnight tonight" is not necessary for a colposcopy. Unlike some surgical procedures that require general anesthesia, a colposcopy is usually done with local anesthesia, and fasting is not required.
Choice D reason:
The statement "You will have general anesthesia during this procedure" is incorrect. General anesthesia is not typically used for a colposcopy. The procedure may cause some discomfort, but it is usually performed using local anesthesia or no anesthesia at all.
Correct Answer is B
Explanation
Choice A reason:
The statement that the prosthesis will be adjustable depending on what shoe you are wearing is not accurate. Prostheses are custom-made to fit the individual and are not typically adjustable to different shoe types. The fit and alignment of the prosthesis are crucial for comfort and function, and these are not dependent on the footwear.
Choice B reason:
It is true that clients will need to do special exercises in advance of getting their prosthesis. These exercises are designed to strengthen the remaining limb and prepare the body for the use of a prosthesis. They are an essential part of rehabilitation and help ensure the best possible outcome for the client.
Choice C reason:
Clients are not fitted for their prosthesis at the time of surgery. Fitting for a prosthesis typically occurs after the residual limb has sufficiently healed, which can take several weeks. The fitting process involves careful measurement and customization to ensure the prosthesis will be comfortable and functional.
Choice D reason:
While a special dressing is applied postoperatively, its primary purpose is not to cushion the prosthesis. Initially, dressings are used to protect the surgical site, control swelling, and promote healing. The prosthesis is fitted after the residual limb has healed, and at that time, different types of socket liners may be used for cushioning.
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