A nurse in an urgent care facility is collecting data from a client who was stung by a wasp. Which of the following findings indicates the client is experiencing anaphylaxis?

Bilateral tinnitus

Difficulty swallowing

Hypertension

Petechial rash on the abdomen

Answer and Explanation

The Correct Answer is B

Nursing Test Bank

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Correct Answer is B

No explanation

A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter C. Tenderness at the injection site D. Palpable area of induration, greater than 10 mm (0.4 in) in diameter

Correct Answer is D

Explanation

Palpable area of induration, greater than 10 mm (0.4 in) in diameter. This indicates a positive tuberculin skin test (TST) reaction for a person with no known risk factors for TB infection. A positive TST reaction means that the person has been infected with Mycobacterium tuberculosis, the bacterium that causes TB disease, and needs further testing to confirm the diagnosis and rule out active TB disease.

The other choices are not correct because:

- Choice A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter. This indicates a negative TST reaction for any person, regardless of their risk factors for TB infection. A negative TST reaction means that the person has not been infected with Mycobacterium tuberculosis or has a very low level of immune response to the bacterium.

- Choice B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter. This indicates a bruise or bleeding under the skin, not a TST reaction. Ecchymosis is not caused by the injection of tuberculin purified protein derivative (PPD) into the skin, but by trauma or injury to the blood vessels.

- Choice C. Tenderness at the injection site. This indicates a mild local reaction to the injection of tuberculin PPD into the skin, not a TST reaction. Tenderness is not measured in millimeters of induration (firm swelling), which is the standard way of reading TST results.

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A nurse in an urgent care facility is collecting data from a client who was stung by a wasp. Which of the following findings indicates the client is experiencing anaphylaxis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has partial-thickness burns on 50% of his body and is receiving total parenteral nutrition. The nurse should actively monitor the client for which of the following?

Correct Answer is B

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Correct Answer is D

Explanation

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