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:
Annular lesions are ring-shaped with a clear center, which does not describe a lesion with a wavy border. This term is typically used for lesions like ringworm, which present as circular rashes with normal skin in the center.

Choice B reason:
Circinate lesions are also circular but are not characterized by a wavy border. They are similar to annular lesions but often have a more rounded edge and are associated with conditions like psoriasis.

Choice C reason:
Coalesced lesions refer to multiple lesions that have merged to form a larger one. While they can have irregular borders, 'coalesced' does not specifically describe the wavy nature of the border.

Choice D reason:
Serpiginous lesions have a wavy or snake-like border, which matches the description provided by the nurse. This term is often used for parasitic infections, such as cutaneous larva migrains, which create a trail-like pattern on the skin.

A. Mucositis B. Bleeding C. Impaction D. Diarrhea

Correct Answer is C

Explanation

Choice A reason:
Mucositis is an inflammation of the mucous membranes lining the digestive tract, which is commonly associated with chemotherapy and radiation therapy, not directly with opioid use. While it can be a concern for cancer patients, it is not a typical side effect of opioids.

Choice B reason:
Bleeding is not a common side effect of opioid medications. While cancer patients may experience bleeding due to various reasons, including the cancer itself or treatment-related issues, opioids do not typically cause bleeding.

Choice C reason:
Opioid-induced constipation (OIC) is a common side effect of opioid medications due to their action on the gastrointestinal tract. Opioids reduce gastrointestinal motility, leading to constipation, which can progress to impaction if not managed properly. This is a manifestation that nurses should anticipate and manage proactively in clients taking opioid medications for pain management.

Choice D reason:
Diarrhea is not typically associated with opioid use. In fact, opioids are more likely to cause constipation rather than diarrhea. Diarrhea may occur as a result of other treatments or conditions but is not a direct side effect of opioids.

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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

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Explanation

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