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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Holding a debriefing is post-incident, not a priority during restraint use; observing movement ensures safety. Assuming debriefing is immediate risks neglecting client monitoring, potentially causing injury, critical to avoid in ensuring safe restraint use and client well-being in acute behavioral situations.
Choice B reason: Observing range of movement during restraints ensures proper application, preventing injury like nerve damage or circulation issues, critical for client safety. This ongoing assessment adheres to restraint protocols, essential for minimizing harm, ensuring ethical care, and supporting de-escalation in aggressive clients.
Choice C reason: Maintaining sensory stimulation is inappropriate during restraints, as it may escalate agitation; observing movement is priority. Assuming stimulation is needed risks worsening aggression, potentially prolonging restraint use, critical to avoid in ensuring calm and safe management of clients in mechanical restraints.
Choice D reason: Identifying stressors is important but secondary to ensuring physical safety by observing movement during restraints. Assuming stressors are the immediate focus risks neglecting restraint safety, potentially causing injury, critical to prevent in ensuring proper monitoring and care in aggressive client situations.
Correct Answer is A
Explanation
Choice A reason: Wearing gloves prevents nicotine absorption through the nurse’s skin during patch application, ensuring safety and preventing side effects like dizziness. This adheres to standard precautions, critical for occupational health, maintaining hygiene, and ensuring effective nicotine therapy for clients in smoking cessation programs.
Choice B reason: Removing the previous patch is correct but placing it in tissue is inadequate; it should be folded and disposed in a sharps container. Assuming tissue disposal is sufficient risks improper handling, potentially exposing others to nicotine, critical to avoid in safe patch management.
Choice C reason: Applying the patch within 1 hour of pouch removal is unnecessary; patches remain stable longer. Wearing gloves is priority. Assuming time restriction risks rushed application, potentially compromising technique, critical to prevent in ensuring safe and effective nicotine patch therapy for smoking cessation.
Choice D reason: Shaving hairy areas risks skin irritation; trimming is preferred before patch application. Wearing gloves is essential. Assuming shaving is correct risks skin damage, reducing patch adhesion, critical to avoid in ensuring proper application and effective nicotine delivery in smoking cessation therapy.
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