A nurse is assessing a client who received a Mantoux skin test 72 hr ago for tuberculosis screening. Which of the following findings indicates a positive test result?
A blister-like area
A cool, blanched area
An elevated, hardened area
An area of ecchymosis
The Correct Answer is C
Rationale:
A. A blister-like area: Blistering is not the expected reaction used to interpret a Mantoux test. The result is based on the presence and size of induration, not the formation of blisters.
B. A cool, blanched area: Coolness and blanching are not indicators of a positive test. These findings may reflect poor circulation or local skin reaction unrelated to tuberculosis screening.
C. An elevated, hardened area: Induration (elevated, firm area) at the injection site, measured in millimeters, is the basis for determining a positive result. The size threshold for positivity depends on the client’s risk factors for tuberculosis.
D. An area of ecchymosis: Bruising at the site is a local skin reaction that can occur after any injection and is unrelated to the diagnostic criteria for a positive Mantoux test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B,C"},"B":{"answers":"B"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"}}
Explanation
- Lymphadenopathy: Generalized lymphadenopathy, or swelling of the lymph nodes, is a common symptom of measles and rubella, but not typically a defining feature of fifth disease.
- Koplik spots in the mouth: Pathognomonic for measles, appearing as tiny white lesions on the buccal mucosa before the rash. Their presence essentially confirms measles over other viral exanthems.
- Red rash on the face: Occurs in all three illnesses but with different patterns — measles starts at the hairline and spreads downward, rubella begins on the face and spreads quickly, and fifth disease presents with a “slapped cheek” appearance before spreading.
- Fever: Common to all three conditions but differs in severity — measles typically produces higher fevers, rubella causes mild fever, and fifth disease may have low-grade fever or none.
Correct Answer is B
Explanation
Rationale:
A. "I will use an interpreter when providing client teaching.": An interpreter is useful for clients with language barriers. Expressive aphasia affects speech production, not comprehension, so an interpreter would not address the main communication challenge.
B. "I will use a communication board to assess the client's needs.": A communication board allows the client to point to words, pictures, or symbols to express thoughts and needs without relying on verbal speech. This is an effective method for facilitating communication with expressive aphasia.
C. "I will provide written instructions for the client in 8-point font.": Written instructions can help if reading skills are intact, but 8-point font is too small for easy readability, especially for clients who may also have vision changes. Larger, clear print is recommended.
D. "I will use indirect lighting in the client's room.": Lighting preferences may improve comfort, but they do not address the core communication difficulty caused by expressive aphasia. This intervention is unrelated to improving the client-nurse communication.
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