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

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.

Nursing Test Bank

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Correct Answer is D

Explanation

"I will try to maintain my blood pressure around 116/72." This is because maintaining blood pressure within a normal range can help prevent heart disease. Choice A is incorrect because increasing dairy intake can lead to a higher intake of saturated fats which can increase the risk of heartdisease.

Choice B is incorrect because lowering, not raising, LDL cholesterol is essential in preventing heart disease.

Choice C is incorrect because exercising only twice a week for 25 minutes is not enough to prevent heart disease.

An explanation for why the other choices are not answers: A – Increasing dairy intake can lead to a higher intake of saturated fats which can increase the risk of heart disease, so this is not the correct statement. B – Lowering, not raising, LDL cholesterol is essential in preventing heart disease, so this is not the correct statement. C – Exercising only twice a week for 25 minutes is not enough to prevent heart disease. Thus, this is not the correct statement.

A. "I should consume fish once per week." B. "With a BMI of 30, I should focus on maintaining my current weight." C. "I should consume no more than 2,000 milligrams of sodium per day." D. "I should exercise for 30 minutes three times per week."

Correct Answer is C

Explanation

"I should consume no more than 2,000 milligrams of sodium per day." This is an appropriate statement because consuming too much sodium is associated with an increased risk for hypertension.

Choice A is not correct because there is not enough evidence to support the idea that consuming fish once per week can prevent hypertension.

Choice B is not correct because maintaining a healthy weight is important, but is not as directly related to preventing hypertension as reducing sodium intake.

Choice D is not correct because exercising 30 minutes three times per week is not enough to prevent hypertension.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about heart disease prevention. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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