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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Mucositis is an inflammation of the mucous membranes lining the digestive tract, which is commonly associated with chemotherapy and radiation therapy, not directly with opioid use. While it can be a concern for cancer patients, it is not a typical side effect of opioids.
Choice B reason:
Bleeding is not a common side effect of opioid medications. While cancer patients may experience bleeding due to various reasons, including the cancer itself or treatment-related issues, opioids do not typically cause bleeding.
Choice C reason:
Opioid-induced constipation (OIC) is a common side effect of opioid medications due to their action on the gastrointestinal tract. Opioids reduce gastrointestinal motility, leading to constipation, which can progress to impaction if not managed properly. This is a manifestation that nurses should anticipate and manage proactively in clients taking opioid medications for pain management.
Choice D reason:
Diarrhea is not typically associated with opioid use. In fact, opioids are more likely to cause constipation rather than diarrhea. Diarrhea may occur as a result of other treatments or conditions but is not a direct side effect of opioids.
Correct Answer is C
Explanation
Choice A reason:
Skin traction is indeed less restrictive than skeletal traction, allowing for more mobility. It is applied using bandages or adhesive material to the skin, which can be removed or adjusted more easily than the pins or screws used in skeletal traction. This type of traction is typically used for short-term treatment before surgery or when the injury is less severe.
Choice B reason:
Discomfort levels can vary depending on the individual and the specific circumstances of the traction. However, skin traction is generally considered to be less painful than skeletal traction because it is less invasive and applies less force. Skeletal traction, which involves the insertion of pins or wires directly into the bone, is likely to cause more discomfort due to the invasive nature of the procedure.
Choice C reason:
Skeletal traction is more appropriate for reducing fractures, especially in cases where a greater force is needed to align the bones. It involves the surgical insertion of pins or wires directly into the bone, allowing for a stronger and more stable pull that is necessary for the realignment of complex fractures.
Choice D reason:
Skeletal traction carries a higher risk of infection compared to skin traction because it is more invasive. The insertion of pins or wires into the bone creates a potential entry point for bacteria, which can lead to infection at the site of insertion.
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