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.

Nursing Test Bank

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Correct Answer is D

Explanation

The correct answer is: d. Hypoglycemia

Choice A reason:

Hyperglycemia: This statement is wrong because hyperglycemia typically presents with symptoms like increased thirst, frequent urination, and fatigue, not sweating and anxiety.

Choice B reason:

Nephropathy: This statement is wrong because nephropathy, a kidney complication, does not cause acute symptoms like sweating and anxiety. It usually presents with proteinuria and progressive kidney dysfunction.

Choice C reason:

Ketoacidosis: This statement is wrong because diabetic ketoacidosis usually presents with symptoms like fruity breath, nausea, vomiting, and deep, rapid breathing (Kussmaul respirations), not sweating and anxiety.

Choice D reason:

Hypoglycemia: This statement is correct because hypoglycemia is characterized by symptoms such as sweating, anxiety, palpitations, and confusion due to the release of adrenaline in response to low blood glucose levels.

A. Bradycardia B. Moist mucous membranes C. Urine specific gravity 1.002

Correct Answer is C

Explanation

Choice A reason:
Bradycardia, which is a slower than normal heart rate, is not typically associated with diabetes insipidus. Diabetes insipidus primarily affects the kidneys and fluid balance in the body, leading to frequent urination and thirst but not directly affecting heart rate.

Choice B reason:
Moist mucous membranes are not expected in diabetes insipidus. In fact, due to excessive urination, a person with diabetes insipidus is more likely to experience dry mucous membranes from dehydration unless they are adequately hydrating.

Choice C reason:
Urine specific gravity 1.002 is a key finding in diabetes insipidus. This condition is characterized by the excretion of large amounts of dilute urine with low specific gravity. Normal urine specific gravity ranges from 1.005 to 1.030⁴. A value of 1.002 indicates very dilute urine, which is consistent with the inability of the kidneys to concentrate urine in diabetes insipidus.

Choice D reason:
Bounding peripheral pulses are not a finding associated with diabetes insipidus. Bounding pulses may be associated with other conditions such as fever, anemia, or hyperthyroidism but not typically with diabetes insipidus.

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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 who has type 1 diabetes mellitus and finds the client lying in bed, sweating, and reporting feeling anxious. Which of the following complications should the nurse suspect?

Correct Answer is D

Explanation

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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