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. Playing with a jump rope: Jump rope requires advanced gross motor coordination and balance, which typically develops around age 4–5 years. A 30-month-old is not developmentally ready for this activity.
B. Playing with a large plastic truck: Toddlers around 2–3 years enjoy manipulating large toys such as trucks, cars, or blocks. This play supports fine and gross motor skills, hand-eye coordination, and imaginative exploration appropriate for their developmental stage.
C. Playing with dress-up clothes: Pretend or dress-up play becomes more common around age 3–4 years, as symbolic thinking and role-playing abilities develop. A 30-month-old may begin simple pretend play but usually engages in more concrete, manipulative play.
D. Playing with an imaginary friend: Engaging in complex imaginative play, such as interacting with an imaginary friend, usually emerges around age 3–4 years, reflecting more advanced cognitive and social development than expected at 30 months.
Correct Answer is B
Explanation
A. Instruct the client to flex the right knee every 30 min: After a femoral cardiac catheterization, the affected leg should remain straight to prevent bleeding or hematoma formation. Flexing the knee could disrupt hemostasis at the insertion site.
B. Assess the client's peripheral pulses every 15 min: Frequent monitoring of peripheral pulses ensures early detection of vascular complications such as thrombosis, occlusion, or impaired circulation in the affected limb.
C. Change the client's dressing 4 hr following the procedure: The initial dressing is typically left intact for several hours or until bleeding is controlled. Early dressing changes are unnecessary and may increase infection risk.
D. Elevate the head of the client's bed to 45°: Elevating the head of the bed can increase pressure on the femoral insertion site and risk bleeding. The client’s bed is usually kept flat or slightly elevated according to provider orders until hemostasis is confirmed.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.