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 D
Explanation
Choice A reason:
Dyspepsia, commonly known as indigestion, is not typically associated with SIADH. It is a condition characterized by chronic or recurrent pain in the upper abdomen and is not linked to the overproduction of antidiuretic hormone.
Choice B reason:
Osteoarthritis is a degenerative joint disease and does not cause SIADH. It is characterized by the breakdown of joint cartilage and underlying bone, most commonly from middle age onward, causing pain and stiffness, especially in the hip, knee, and thumb joints.
Choice C reason:
Liver cirrhosis can lead to complications that may contribute to fluid imbalance, but it is not a direct cause of SIADH. SIADH is more commonly associated with conditions that affect the central nervous system or certain types of cancer.
Choice D reason:
Lung cancer, particularly small cell lung cancer, is a well-known cause of SIADH. Tumors in the lungs can produce and release antidiuretic hormone independently, leading to the syndrome of inappropriate antidiuretic hormone secretion.
Correct Answer is C
Explanation
Choice A reason:
The statement "HIPAA is a federal law, not a state law" is correct. HIPAA is indeed a federal law that provides national standards to protect the privacy of personal health information.
Choice B reason:
The statement "HIPAA established regulations for individually identifiable health information in verbal, electronic, or written form" is also correct. HIPAA does regulate how individually identifiable health information should be protected and handled across various forms of communication.
Choice C reason:
The statement "Information about a client can be disclosed to family members at any time" indicates a need for further teaching. Under HIPAA, protected health information can only be disclosed to family members under certain conditions, such as when the patient has given permission or when it is directly relevant to the family member's involvement in the patient's care.
Choice D reason:
The statement "A client's address would be an example of personally identifiable information" is correct. Under HIPAA, a client's address is considered personally identifiable information, which is protected and cannot be disclosed without proper authorization.
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