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 D
Explanation
The correct answer is: D.
Choice A reason: Asking a patient to rate their pain on a scale from 0 to 10 is a common method to assess the intensity of pain, not the quality. Zero indicates no pain, and ten represents the most severe pain imaginable. This scale is quantitative and helps in tracking the effectiveness of pain management over time.
Choice B reason: Inquiring if the pain is the same as it has been is a question that assesses the consistency or changes in the patient’s pain over time. It does not provide information about the quality of the pain but rather its course or any variations in the experience of pain.
Choice C reason: Asking whether the patient has any pain this morning is a question that determines the presence or absence of pain at a particular time. It does not elicit details about the nature or characteristics of the pain, which are essential to understanding its quality.
Choice D reason: Asking “What does your pain feel like?” is a qualitative question that aims to describe the characteristics of the pain, such as aching, stabbing, or burning. This information is crucial for diagnosing the cause of pain and tailoring appropriate treatment strategies. It directly addresses the quality of the pain, which is the focus of the nurse’s inquiry.
Correct Answer is D
Explanation
Ginkgo biloba is a herb that can interact with enoxaparin and increase the risk of bleeding, so the nurse should report its use to the provider. The other options, A (Echinacea), B (Flaxseed powder), and C (Probiotics) do not have any known interactions with enoxaparin, so they do not need to be reported to the provider.
Reasons, why the other choices are not answers, are:
A. Echinacea is a herb that is commonly used to boost the immune system and has not been found to interact with enoxaparin.
B. Flaxseed powder is a dietary supplement that is high in fiber and omega-3 fatty acids and has not been found to interact with enoxaparin.
C. Probiotics are live bacteria that can be found in certain foods or supplements, and they have not been found to interact with enoxaparin.
In summary, the nurse should report the use of Ginkgo biloba to the provider, as it can interact with enoxaparin and increase the risk of bleeding. Echinacea, Flaxseed powder, and Probiotics do not have any known interactions with enoxaparin, so they do not need to be reported to the provider.
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