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
While GERD (gastroesophageal reflux disease) can be exacerbated by hormone therapy due to its potential effect on the lower esophageal sphincter, it is not typically a contraindication for HT unless the GERD is severe and not well controlled with treatment.
Choice B reason:
A history of breast cancer is a contraindication for hormone therapy. Estrogen can stimulate the growth of hormone receptor-positive breast cancers, and therefore, HT is not recommended for individuals with a current or past history of breast cancer.
Choice C reason:
COPD (chronic obstructive pulmonary disease) is not a contraindication for HT. While patients with COPD may have other comorbidities that could affect the safety of HT, COPD alone does not preclude the use of hormone therapy.
Choice D reason:
Dermatitis, or inflammation of the skin, is not a contraindication for HT. Skin conditions are not typically affected by hormone therapy, and HT may sometimes be beneficial for skin health during menopause.
Correct Answer is D
Explanation
Choice A reason: Positive Trousseau's sign
Trousseau's sign is indicative of hypocalcemia, not CTS. It is elicited by inflating a blood pressure cuff on the upper arm to above systolic pressure for 3 minutes. A positive sign is characterized by carpal spasm, which is not related to CTS.
Choice B reason: Cool extremities
Cool extremities can be a result of various conditions, including peripheral vascular disease or hypothyroidism. They are not a specific indicator of CTS, which primarily affects nerve function rather than blood circulation or temperature regulation.
Choice C reason: Decreased radial pulse
A decreased radial pulse is not typically associated with CTS. It may indicate a cardiovascular issue or a blockage in the radial artery, which would require further investigation unrelated to CTS.
Choice D reason: Positive Phalen's sign
Phalen's sign is a diagnostic test for CTS. The test is performed by having the patient flex their wrist maximally and hold the position for about 60 seconds. A positive Phalen's sign, which includes numbness and tingling in the thumb, index finger, middle finger, and the radial half of the ring finger, is indicative of CTS. This occurs due to increased pressure on the median nerve when the wrist is in flexion.
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