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 A
Explanation
Choice A Reason:
Administering a prescribed oral dose of trazodone to the client is correct. Trazodone is sometimes used to manage agitation in patients with Alzheimer's disease, as it has calming effects and can help reduce agitation and anxiety. However, the use of any medication should be based on the client's individualized treatment plan and prescribed by a healthcare provider.
Choice B Reason:
Encouraging ambulation might not be suitable if the client is agitated, as it could potentially escalate the situation or increase the risk of falls or injury. Safety should be a priority, and ambulation might not be advisable during a state of agitation.
Choice C Reason:
Isolating the client in their room is incorrect. Isolating the client might increase feelings of confusion, fear, or distress, potentially worsening the agitation. It's important to engage and support the client rather than isolate them, which can be distressing for someone with Alzheimer's disease.
Choice D Reason:
Applying bilateral wrist restraints to the client is incorrect. The use of restraints should only be considered as a last resort when all other measures have failed and when there's an immediate risk of harm to the client or others. Restraints can be physically and psychologically harmful, leading to increased agitation, anxiety, and potential injury. They should be used only under strict guidelines and with proper authorization when all other interventions have been exhausted.
Correct Answer is B
Explanation
Choice A Reason:
Temperature 37.3°C (99.1°F) is incorrect . While a slightly elevated temperature can sometimes accompany an infection, it's not specific to a bladder infection and might not be present in all cases.
Choice B Reason:
Changed mental status is incorrect. Bladder infections or urinary tract infections (UTIs) in older adults can often present with atypical symptoms, and changes in mental status or acute confusion are common indicators in this population. UTIs can cause subtle but significant alterations in mental function, particularly in the elderly, leading to confusion, agitation, or cognitive impairment.
Choice C Reason:
WBC count 9,000/mm3 (5000 to 10,000/mm3) is incorrect .A WBC count within the normal range doesn't necessarily rule out or confirm a bladder infection. In some cases, UTIs might not significantly elevate the white blood cell count, especially in localized infections.
Choice D Reason:
Diminished reflexes is incorrect . Diminished reflexes are not typically associated with a bladder infection. They might indicate other neurological or muscular issues but are not a common sign of a UTI.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
