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?

Choice A reason: Using an eight electric razor reduces bleeding risk in clients on warfarin, an anticoagulant that increases bleeding tendency, critical for safety. This instruction prevents cuts, essential for minimizing hemorrhage, supporting adherence, and ensuring safe daily activities in clients managing anticoagulation therapy.

Choice B reason: Milk products do not interact with warfarin; consistent vitamin K intake is key. Assuming milk avoidance is needed risks unnecessary dietary restriction, potentially affecting nutrition, critical to avoid in ensuring accurate dietary education for clients on warfarin therapy.

Choice C reason: Back pain is not a common warfarin side effect; bleeding is the primary concern. Assuming back pain is related risks misinforming the client, potentially causing unnecessary worry, critical to prevent in ensuring accurate education and safety for clients on anticoagulation therapy.

Choice D reason: Sunlight exposure does not significantly affect warfarin; photosensitivity is unrelated. Assuming sunlight avoidance is needed risks unnecessary lifestyle restrictions, critical to avoid in ensuring accurate teaching, focusing on bleeding precautions, and supporting safe warfarin use in clients requiring anticoagulation.

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.