A nurse in a community health center is assessing the results of a tuberculin skin test she performed on a client. Which of the following results indicates exposure to and a possible infection with tuberculosis (TB)?

10 mm wheal

5 mm induration

15 mm induration

4 mm erythema

Answer and Explanation

The Correct Answer is C

Choice A Reason:
A 10 mm wheal is not indicative of TB infection. A wheal is a raised, often itchy area of skin that usually signifies an allergic reaction, not an infection. The TST looks for induration, which is a firm swelling, as a sign of TB infection.

Choice B Reason:
A 5 mm induration is considered positive in certain high-risk groups, such as people living with HIV, recent contacts of TB patients, or those with a history of organ transplants. For individuals without these risk factors, a 5 mm induration is not considered a positive result.

Choice C Reason:
A 15 mm induration is considered a positive TST result for individuals with no known risk factors for TB. This indicates that the person's immune system has reacted to the tuberculin purified protein derivative (PPD) injected under the skin, suggesting exposure to TB bacteria.

Choice D Reason:
Erythema, or redness of the skin, is not measured when interpreting TST results. The test measures induration, which is a palpable, raised, hardened area or swelling. Therefore, a 4 mm erythema does not indicate TB infection.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason:
The inability to move toes can be an early sign that a cast is too tight. This symptom may indicate that the cast is impinging on nerves or blood vessels, leading to decreased motor function. It is essential to address this immediately to prevent further complications such as permanent damage or compartment syndrome.

Choice B reason:
Edema, or swelling of the toes, can occur if a cast is too tight, but it may not be the first sign observed. Swelling is a response to increased pressure in the tissues and can develop over time as fluid accumulates. While it is a concern, it often follows other symptoms such as changes in sensation or movement.

Choice C reason:
Pallor of the toes, indicating reduced blood flow, can be a sign of a cast that is too tight. However, pallor may not be as immediately noticeable as the inability to move toes or changes in sensation. It is still a critical sign that requires prompt evaluation and possible adjustment of the cast.

Choice D reason:
A change in the temperature of the toes, such as them becoming cooler to the touch, can suggest impaired blood flow due to a tight cast. This sign, along with pallor, may develop after other symptoms such as numbness or motor impairment.

A. Hay fever allergy B. Anaphylaxis C. Transplant rejection D. Bacterial phagocytosis

Correct Answer is C

Explanation

Choice A reason:
Hay fever allergy, also known as allergic rhinitis, is primarily associated with the action of Immunoglobulin E (IgE) antibodies and not directly with T-cells. T-cells can contribute to the regulation of the immune response in allergies, but IgE is the main immunoglobulin involved in the typical symptoms of hay fever.

Choice B reason:
Anaphylaxis is a severe, potentially life-threatening allergic reaction that involves the release of large amounts of histamine and other chemicals from mast cells and basophils, often triggered by IgE antibodies. While T-cells can play a role in the sensitization phase of allergy, anaphylaxis itself is not directly caused by T-cells.

Choice C reason:
Transplant rejection is a process in which T-cells play a central role. When a transplant recipient's immune system recognizes the donated organ as foreign, T-cells can mediate the rejection by attacking the transplanted tissue, leading to its failure.

Choice D reason:
Bacterial phagocytosis is primarily the function of phagocytes like neutrophils and macrophages. T-cells are involved in the adaptive immune response and can activate phagocytes, but they do not directly perform phagocytosis.

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A nurse in a community health center is assessing the results of a tuberculin skin test she performed on a client. Which of the following results indicates exposure to and a possible infection with tuberculosis (TB)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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