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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?

A.

Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter

B.

Area of ecchymosis, greater than 12 mm (0.5 in) in diameter

C.

Tenderness at the injection site

D.

Palpable area of induration, greater than 10 mm (0.4 in) in diameter

Answer and Explanation

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. 


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Correct Answer is A

Explanation

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Choice B: Atorvastatin does not contain sulfa and is safe for clients with a sulfa allergy.

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Correct Answer is A

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Choice C is not correct because benzoyl peroxide is used to treat acne, not psoriasis.

Choice D is not correct because oil-based ointments can actually make psoriasis worse.

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