A nurse is assessing a client who received a Mantoux skin test 72 hours ago for tuberculosis screening. Which of the following findings indicates a positive test result?

A blister-like area.

An area of ecchymosis.

A cool, blanched area.

An elevated, hardened area.

Answer and Explanation

The Correct Answer is D

Choice A reason: A blister-like area is not indicative of a positive Mantoux test, which shows induration; blisters suggest irritation. Assuming blisters are positive risks misdiagnosis, potentially missing tuberculosis exposure, critical to avoid in ensuring accurate screening and follow-up in clients tested for TB.

Choice B reason: Ecchymosis (bruising) is not a positive Mantoux result; induration indicates exposure. Assuming ecchymosis is positive risks incorrect interpretation, potentially overlooking tuberculosis risk, critical to prevent in ensuring proper screening, diagnosis, and follow-up for clients undergoing TB skin testing.

Choice C reason: A cool, blanched area suggests no reaction, not a positive Mantoux test, which requires induration. Assuming blanching is positive risks missing exposure, critical to avoid in ensuring accurate tuberculosis screening, guiding appropriate diagnostic follow-up, and protecting client and public health.

Choice D reason: An elevated, hardened area (induration) at 72 hours indicates a positive Mantoux test, suggesting TB exposure, requiring further evaluation. This is critical for accurate screening, ensuring timely diagnosis, preventing disease spread, and guiding follow-up in clients tested for tuberculosis exposure.

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Correct Answer is B

Explanation

Choice A reason: Playing with a jump rope requires advanced coordination, typical of older children, not 30-month-olds, who engage in simpler play like trucks. Assuming jump rope is appropriate risks overestimating development, potentially frustrating the child, critical to avoid in supporting age-appropriate activities for toddlers.

Choice B reason: Playing with a large plastic truck is developmentally appropriate for a 30-month-old, supporting gross motor and imaginative play, critical for cognitive and physical development. This activity aligns with toddler abilities, essential for fostering engagement, creativity, and motor skills in early childhood care settings.

Choice C reason: Imaginary friends typically emerge around 3-4 years, not at 30 months, when simpler play like trucks is common. Assuming imaginary play is expected risks misjudging development, potentially overlooking age-appropriate activities, critical to prevent in supporting toddler engagement and growth.

Choice D reason: Dress-up play is more typical for preschoolers (3-5 years), requiring advanced imagination beyond 30-month-olds, who prefer trucks. Assuming dress-up is appropriate risks developmental mismatch, potentially reducing engagement, critical to avoid in ensuring age-appropriate activities for toddlers in care settings.

A. I will use a communication board to assess the client’s needs. B. I will use an interpreter when providing client teaching. C. I will use indirect lighting in the client’s room. D. I will collaborate with a speech therapist about the client’s plan of care.

Correct Answer is C

Explanation

Choice A reason: A communication board is for speech or cognitive issues, not visual impairment, where indirect lighting aids vision. Assuming a board is appropriate risks ineffective communication, potentially frustrating the client, critical to avoid in ensuring clear interaction for visually impaired clients in care settings.

Choice B reason: An interpreter is for language barriers, not visual impairment, where indirect lighting enhances visibility. Assuming an interpreter is needed risks misaligned communication strategies, potentially reducing clarity, critical to prevent in ensuring effective teaching and interaction for clients with visual impairments.

Choice C reason: Indirect lighting reduces glare, improving visibility for visually impaired clients, enhancing communication and safety. This understanding is critical for effective interaction, ensuring client comfort, promoting independence, and supporting accurate information exchange, essential for care delivery in clients with visual impairments.

Choice D reason: Collaborating with a speech therapist addresses speech issues, not visual impairment, where indirect lighting is key. Assuming therapist involvement is relevant risks overlooking visual needs, potentially reducing communication efficacy, critical to avoid in supporting visually impaired clients in healthcare settings.

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A nurse is assessing a client who received a Mantoux skin test 72 hours ago for tuberculosis screening. Which of the following findings indicates a positive test result?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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