An occupational health nurse is interpreting the results of a tuberculin skin test for a group of clients who received the test 48 hr ago. Which of the following clients should the nurse identify as having a positive test result?
A client whose injection site is scabbed
A client whose injection site is firm and measures 3 mm (0.1 in)
A client whose injection site has an elevated area measuring 15 mm (0.6 in)
A client whose injection site is ecchymotic
The Correct Answer is C
Choice A Reason:
A client whose injection site is scabbed is incorrect. Scabbing at the injection site does not provide information about the presence or absence of induration. It doesn't contribute to interpreting the test result directly.
Choice B Reason:
A client whose injection site is firm and measures 3 mm (0.1 in) is incorrect. A measurement of 3 mm of induration is generally considered a negative result for most individuals, including those without any risk factors for tuberculosis (TB).
Choice C Reason:
A client whose injection site has an elevated area measuring 15 mm (0.6 is correct. An area of induration measuring 15 mm or more is considered positive in individuals with no known risk factors for TB.
Choice D Reason:
A client whose injection site is ecchymotic is incorrect. Ecchymosis (bruising) at the injection site is not relevant to the interpretation of the tuberculin skin test. It does not contribute to determining a positive or negative result.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a.While enemas may be part of bowel preparation, they are usually administered closer to the procedure, not 2 days in advance.
b.This is a standard bowel preparation instruction for colonoscopy to ensure a clear view of the colon during the procedure.
c.A clear liquid diet for a shorter period, usually 12-24 hours, is sufficient.
d.Removing polyps during a colonoscopy is a common procedure and does not necessarily require a separate procedure.
Correct Answer is C
Explanation
Choice A Reason:
"You will not become fatigued when you use assistive devices. “This statement might provide an unrealistic expectation. While assistive devices can help, they might still require physical effort and could potentially cause fatigue, especially during initial use or extended periods.
Choice B Reason:
"Plan to hire a home care aid to perform all of your ADLs." This statement is not appropriate.
While home care assistance can be beneficial, aiming to have someone perform all ADLs might limit the client's independence and ability to regain skills. The goal is often to support the client in performing ADLs independently whenever possible.
Choice C Reason:
"Install grab bars in your shower to assist with your balance." This statement is true. Installing grab bars in the shower can significantly enhance safety and stability during activities like showering, reducing the risk of falls for someone who might experience balance or mobility challenges following a CVA.
Choice D Reason:
"Place a towel in the shower to prevent slipping." This statement is inappropriate. While placing a towel might offer some traction, it might not provide sufficient stability or support, especially for someone with balance issues post-CVA. Grab bars offer more reliable support to prevent falls in the shower.
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