A nurse is assisting with care for a client who received a tuberculin skin test 72 hr ago. When collecting data from the test site, which of the following findings indicates a need for further testing?
Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter
Area of ecchymosis, greater than 12 mm (0.5 in) in diameter
Tenderness at the injection site
Palpable area of induration, greater than 10 mm (0.4 in) in diameter
The Correct Answer is D
Palpable area of induration, greater than 10 mm (0.4 in) in diameter. This indicates a positive tuberculin skin test (TST) reaction for a person with no known risk factors for TB infection. A positive TST reaction means that the person has been infected with Mycobacterium tuberculosis, the bacterium that causes TB disease, and needs further testing to confirm the diagnosis and rule out active TB disease.
The other choices are not correct because:
- Choice A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter. This indicates a negative TST reaction for any person, regardless of their risk factors for TB infection. A negative TST reaction means that the person has not been infected with Mycobacterium tuberculosis or has a very low level of immune response to the bacterium.
- Choice B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter. This indicates a bruise or bleeding under the skin, not a TST reaction. Ecchymosis is not caused by the injection of tuberculin purified protein derivative (PPD) into the skin, but by trauma or injury to the blood vessels.
- Choice C. Tenderness at the injection site. This indicates a mild local reaction to the injection of tuberculin PPD into the skin, not a TST reaction. Tenderness is not measured in millimeters of induration (firm swelling), which is the standard way of reading TST results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
"Consume 500 fewer calories per day than your estimated calorie needs." Consuming slightly fewer calories than one's estimated calorie needs can help promote weight loss in a healthy and safe way. Planningmeals so that up to 40% of calories come from fats is not typically recommendedwhen trying to lose weight, as too much fat can lead to excess calorie intake. Refined grains should be avoided in favor of whole grains, and it is not recommended to reward oneself with special foods for achieving short-termgoals.
Choice B: Planning meals so that up to 40% of calories come from fat is nottypically recommended when trying to lose weight, as too much fat can lead toexcess calorie intake.
Choice C: Refined grains should be avoided in favor of wholegrains.
Choice D: It is not recommended to reward oneself with special foods forachieving short-term goals.
Correct Answer is A
No explanation
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.