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
Explanation
A. Instill erythromycin ointment into the newborn's eyes: Erythromycin ophthalmic ointment is routinely applied to all newborns to prevent ophthalmia neonatorum, a serious eye infection caused by exposure to Neisseria gonorrhoeae during birth.
B. Give oral sulfadiazine to the mother prior to delivery: Sulfonamides are not recommended for gonorrhea treatment in laboring clients and are ineffective in preventing neonatal eye infections.
C. Administer penicillin G procaine IM to the newborn: Penicillin is used to treat confirmed neonatal infections, not as a routine prophylaxis against gonococcal eye infections.
D. Apply miconazole vaginal cream to the mother prior to delivery: Miconazole is an antifungal used for vaginal yeast infections and has no effect on gonorrhea, so it is not indicated for preventing neonatal infection.
Correct Answer is A
Explanation
A. Bradypnea: Hypermagnesemia depresses neuromuscular and central nervous system function, which can lead to slowed respiratory rate (bradypnea) and potentially respiratory failure in severe cases.
B. Personality change: Personality changes are more commonly associated with hyponatremia, hypernatremia, or other electrolyte imbalances affecting the brain, rather than hypermagnesemia.
C. Seizure: Seizures are more likely in hypomagnesemia due to increased neuromuscular excitability, not in hypermagnesemia, which generally causes neuromuscular depression.
D. Elevated hematocrit: Hypermagnesemia does not directly affect red blood cell concentration or hematocrit levels. Changes in hematocrit are usually related to fluid volume status, not magnesium levels.
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