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:
Dark hair is not a recognized risk factor for developing malignant melanoma. Melanoma is more commonly associated with individuals having fair skin, light hair, and light-colored eyes because they have less melanin to protect their skin from UV radiation.
Choice B reason:
While female gender is not a direct risk factor for malignant melanoma, it is important to note that melanoma rates can vary between genders at different ages. Generally, before age 50, melanoma rates are higher in women, but by age 65, rates are twice as high in men.
Choice C reason:
A history of chronic skin irritation or inflammation can potentially increase the risk of developing skin cancer, including melanoma. Chronic inflammation can lead to DNA damage and contribute to the development of cancerous cells.
Choice D reason:
Age 19 to 30 years is not considered a high-risk age group for malignant melanoma. The risk of melanoma increases with age, and it is most frequently diagnosed in older adults, although it is not uncommon in younger people.
Correct Answer is A
Explanation
Choice A reason:
Blood in the urine (hematuria) or semen (hematospermia) can be a sign of advanced prostate cancer. This symptom occurs when the cancer affects the urinary or reproductive tracts, causing bleeding. It is a direct result of the tumor invading nearby tissues or structures.
Choice B reason:
While anemia can be associated with chronic diseases like cancer, it is not a direct manifestation of the advancing disease process of prostate cancer. Anemia in cancer patients is often multifactorial, including chronic inflammation, nutritional deficiencies, or treatment-related side effects.
Choice C reason:
A dark-colored or elevated lesion is not typically associated with prostate cancer. Such lesions are more commonly related to skin cancers or other dermatological conditions.
Choice D reason:
An enlarged liver or gallbladder can be a sign of metastasis in advanced cancer cases, including prostate cancer. However, it is less specific than blood in the urine or semen and can be caused by a variety of other conditions.
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