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A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?

A reddened area measuring 10 mm

A reddened area measuring 5 mm

An induration measuring 5 mm

An induration measuring 10 mm

Answer and Explanation

The Correct Answer is D

A. A reddened area without induration is not a positive result.

B. A reddened area without induration is not considered positive.

C. An induration of 5 mm is positive only for high-risk groups (e.g., immunocompromised clients).

D. An induration measuring 10 mm is considered positive in most adults, indicating TB exposure.

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Correct Answer is A

Explanation

A. Privately interviewing the client is the first step in assessing the possibility of elder abuse and gathering detailed information.

B. Notifying risk management is necessary after abuse is confirmed or suspected, but it is not the first step.

C. Informing the transferring agency is not appropriate until further investigation.

D. Contacting the family may not be appropriate if they are suspected of abuse.

A. feeling short of breath B. pleuritic chest pain C. headache for the past 3 days D. "I woke up feeling worse and started to feel nauseated and couldn't eat my breakfast E. pleuritic chest pain as 6 on a scale of 0 to 10 F. Lungs sounds are diminished in lower lobes with crackles G. nausea

Correct Answer is ["A","B","C","F"]

Explanation

Feeling short of breath:

Rationale: Shortness of breath is a critical symptom, especially in a client with a recent diagnosis of pneumonia (right lower lobe pneumonia seen on chest x-ray). It indicates impaired gas exchange and requires immediate evaluation to ensure the client’s oxygenation needs are being met and that the condition isn’t worsening. Given the oxygen saturation was 88%, this symptom is concerning and requires prompt intervention, such as increasing oxygen therapy.

Pleuritic chest pain:

Rationale: Pleuritic chest pain, often described as sharp or stabbing pain that worsens with breathing or coughing, is commonly associated with conditions like pneumonia or pulmonary embolism. In this case, the client has pneumonia, which can cause inflammation of the pleura (the lining of the lungs) and lead to pain. This symptom requires monitoring and potentially further evaluation to assess the extent of the pneumonia and its complications.

Headache for the past 3 days:

Rationale: A headache lasting several days could be related to the underlying infection or a systemic response to it (fever, dehydration, etc.). Although a headache is not an immediate emergency, it may indicate that the infection is severe or complicated, especially in the context of fever and other systemic symptoms like nausea. It is important to monitor the client's neurological status as part of their overall condition.

Nausea:

Rationale: Nausea, especially in the setting of a respiratory infection like pneumonia, can indicate that the infection is affecting the gastrointestinal system or could be a side effect of medications (e.g., antibiotics). It is important to evaluate the cause of the nausea and address any concerns related to fluid and electrolyte balance, particularly because the client has not been eating well, which could lead to dehydration or malnutrition.

Lung sounds diminished in lower lobes with crackles:

Rationale: Diminished lung sounds with crackles suggest fluid or consolidation in the lungs, which is characteristic of pneumonia. This finding requires immediate attention because it could indicate worsening pneumonia or atelectasis. Monitoring and interventions, such as increased oxygen support, encouraging deep breathing, and using the incentive spirometer, are essential to prevent further respiratory decline.

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A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse?

Correct Answer is A

Explanation

Correct Answer is ["A","B","C","F"]

Explanation

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