A nurse is assessing a patient who reports persistent cough, night sweats, weight loss, and fatigue. The nurse suspects tuberculosis (TB). Which additional symptom would further support this diagnosis?

Nausea and vomiting after eating fatty foods

Sudden high fever and chills with a rash

Wheezing and shortness of breath that improves with bronchodilators

Productive cough with blood (hemoptysis)

Answer and Explanation

The Correct Answer is D

A. Nausea and vomiting after eating fatty foods: This symptom is more commonly associated with gallbladder disease (e.g., cholecystitis) rather than TB.

B. Sudden high fever and chills with a rash: TB typically causes a low-grade fever, night sweats, and progressive weight loss rather than sudden high fevers with a rash, which are more indicative of systemic infections like meningococcemia or viral exanthems.

C. Wheezing and shortness of breath that improves with bronchodilators: While TB can cause respiratory symptoms, it does not typically present with reversible airway constriction like asthma or chronic obstructive pulmonary disease (COPD), which respond to bronchodilators.

D. Productive cough with blood (hemoptysis): Hemoptysis (coughing up blood) is a hallmark symptom of active TB, resulting from lung tissue damage caused by the Mycobacterium tuberculosis infection.

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Correct Answer is C

Explanation

A. Deep Tissue Injury. Deep tissue injuries appear as intact or discolored skin (purple or maroon) due to underlying soft tissue damage. This wound is already open with slough, so it does not fit this category.

B. Stage III Pressure Ulcer. A Stage III pressure ulcer involves full-thickness skin loss with visible subcutaneous tissue, but the wound depth must be assessable. Since the slough covers the wound, the depth cannot be determined.

C. Unstageable Pressure Ulcer. An unstageable pressure ulcer is one where the base of the wound is covered with slough or eschar, preventing assessment of the full depth of tissue damage. Until the slough is removed, the stage cannot be determined.

D. Stage II Pressure Ulcer. A Stage II ulcer has partial-thickness skin loss with exposed dermis, often appearing as an open blister or shallow wound. The presence of thick slough suggests deeper involvement, making this an incorrect classification.

A. “I will reposition every 2 hours to prevent pressure injuries." B. “I should apply warm compresses to any red areas to improve circulation and prevent ulcers." C. “I will encourage a diet rich in vitamin C, zinc, and protein to support skin healing." D. “I should use foam cushions and heel protectors to relieve pressure on bony prominences."

Correct Answer is B

Explanation

A. “I will reposition every 2 hours to prevent pressure injuries." Repositioning every 2 hours is a key preventive measure to relieve pressure and reduce the risk of pressure ulcers. This is an appropriate statement and does not indicate a need for further teaching.

B. “I should apply warm compresses to any red areas to improve circulation and prevent ulcers." This statement indicates a need for further teaching. Applying warm compresses to reddened areas can actually worsen tissue damage by increasing moisture and promoting skin breakdown. Instead, pressure should be relieved from the area immediately.

C. “I will encourage a diet rich in vitamin C, zinc, and protein to support skin healing." A diet high in protein, vitamin C, and zinc helps support skin integrity and promotes wound healing, making this a correct statement.

D. “I should use foam cushions and heel protectors to relieve pressure on bony prominences." Foam cushions and heel protectors help redistribute pressure, reducing the risk of pressure ulcers on bony areas like the sacrum and heels. This statement does not indicate a need for further teaching.

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A nurse is assessing a patient who reports persistent cough, night sweats, weight loss, and fatigue. The nurse suspects tuberculosis (TB). Which additional symptom would further support this diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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