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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","F"]
Explanation
A. Blood pressure. A blood pressure of 162/112 mm Hg is severely elevated and indicative of preeclampsia, a serious complication during pregnancy. Uncontrolled hypertension can lead to maternal and fetal complications, such as eclampsia, placental abruption, or fetal growth restriction.
B. Urine ketones. The absence of ketones in the urine is normal and does not indicate any prenatal complication. Ketones would typically be seen in cases of starvation, dehydration, or poorly controlled diabetes, which are not evident here.
C. Urine protein. The presence of 3+ protein in the urine is a key diagnostic marker for preeclampsia. This finding, combined with elevated blood pressure, signals potential damage to the kidneys, which is a hallmark of severe preeclampsia.
D. Report of headache. A severe headache unrelieved by acetaminophen is a concerning symptom of preeclampsia. It suggests potential central nervous system involvement, which could lead to complications like seizures if left untreated.
E. Respiratory rate. The client’s respiratory rate of 16/min is within the normal range and does not indicate any immediate concern related to her pregnancy or current condition.
F. Fetal activity. The client’s report of decreased fetal movement is concerning and may indicate fetal distress or compromised placental function. This finding requires prompt evaluation to ensure fetal well-being.
Correct Answer is A
Explanation
A. Place the client's hands in warm water: This action can stimulate the client’s natural reflex to urinate. The warm water helps relax the muscles involved in urination.
B. Administer a benzodiazepine: Incorrect. Benzodiazepines are not indicated for difficulty urinating postpartum and can cause unnecessary sedation.
C. Place an ice pack on the client's perineum: Incorrect. An ice pack is typically used to reduce swelling or discomfort, but it is not a primary intervention for urinary retention.
D. Perform a fundal massage: Incorrect. Fundal massage is performed to assess uterine tone, not for urinary retention.
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