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 B
Explanation
A. Teach the client relaxation techniques: Teaching coping strategies is helpful but does not address the immediate need to understand the client’s perception of the crisis. It should follow assessment.
B. Confirm the client's perception of the event: The first step in crisis intervention is to assess and understand the client’s view of the situation. Clarifying perception allows the nurse to accurately prioritize interventions and provide appropriate support.
C. Notify the client's support person: Contacting support is beneficial for ongoing assistance but should occur after assessing the client’s understanding and emotional state.
D. Help the client identify personal strengths: Identifying strengths promotes coping and resilience, but it is a secondary intervention that should follow assessment and clarification of the client’s perception.
Correct Answer is C
Explanation
Rationale:
A. Urine output 20 mL/hr: This urine output is below the recommended minimum of 30 mL/hr and may indicate magnesium toxicity or worsening renal perfusion. It is not a therapeutic effect and requires prompt evaluation.
B. BP 150/92 mm Hg: This blood pressure is still elevated and does not indicate optimal control of preeclampsia. Magnesium sulfate is given to prevent seizures, not primarily to lower blood pressure, so this is not a measure of therapeutic effect.
C. Absence of eclampsia: Magnesium sulfate is administered in preeclampsia to prevent the onset of eclampsia (seizures). The absence of seizure activity indicates that the medication is having its intended therapeutic effect.
D. FHR 116/min: This fetal heart rate is within the normal baseline range of 110–160/min, but it is not a direct therapeutic effect of magnesium sulfate. It is more a reflection of fetal well-being rather than the drug’s primary purpose.
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