A nurse is assessing a client who received a Mantoux skin test 72 hours ago for tuberculosis screening. Which of the following findings indicates a positive test result?

A blister-like area.

An area of ecchymosis.

A cool, blanched area.

An elevated, hardened area.

Answer and Explanation

The Correct Answer is D

Choice A reason: A blister-like area is not indicative of a positive Mantoux test, which shows induration; blisters suggest irritation. Assuming blisters are positive risks misdiagnosis, potentially missing tuberculosis exposure, critical to avoid in ensuring accurate screening and follow-up in clients tested for TB.

Choice B reason: Ecchymosis (bruising) is not a positive Mantoux result; induration indicates exposure. Assuming ecchymosis is positive risks incorrect interpretation, potentially overlooking tuberculosis risk, critical to prevent in ensuring proper screening, diagnosis, and follow-up for clients undergoing TB skin testing.

Choice C reason: A cool, blanched area suggests no reaction, not a positive Mantoux test, which requires induration. Assuming blanching is positive risks missing exposure, critical to avoid in ensuring accurate tuberculosis screening, guiding appropriate diagnostic follow-up, and protecting client and public health.

Choice D reason: An elevated, hardened area (induration) at 72 hours indicates a positive Mantoux test, suggesting TB exposure, requiring further evaluation. This is critical for accurate screening, ensuring timely diagnosis, preventing disease spread, and guiding follow-up in clients tested for tuberculosis exposure.

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Correct Answer is D

Explanation

Choice A reason: Blaming the boss for retirement reflects projection, not compensation, which involves substituting strengths for losses. Gardening competitions show compensation. Assuming blame is compensation risks misidentifying coping, potentially missing adaptive strategies, critical to avoid in supporting psychological adjustment in recently retired clients.

Choice B reason: Expressing relief about retirement reflects rationalization, not compensation, where new activities offset losses. Gardening competitions indicate compensation. Assuming relief is compensation risks misunderstanding coping, potentially overlooking adaptive behaviors, critical to prevent in assessing psychological health in clients post-retirement.

Choice C reason: Journaling about accomplishments reflects sublimation, not compensation, which involves new activities like gardening to offset retirement loss. Assuming journaling is compensation risks misinterpreting coping, potentially missing adaptive strategies, critical to avoid in supporting emotional adjustment in clients navigating retirement transitions.

Choice D reason: Entering gardening competitions post-retirement reflects compensation, substituting new achievements for lost work identity, promoting psychological adjustment. This adaptive coping is critical for mental health, supporting self-esteem, and ensuring positive adaptation, essential for assessing effective coping strategies in clients recently retired from their careers.

A. Elevate the head of the client’s bed to 45°. B. Assess the client’s peripheral pulses every 15 minutes. C. Change the client’s dressing 4 hours following the procedure. D. Instruct the client to flex the right knee every 30 minutes.

Correct Answer is B

Explanation

Choice A reason: Elevating the bed to 45° increases bleeding risk at the femoral site post-catheterization; flat positioning is preferred. Assessing pulses is priority. Elevating risks hematoma, critical to avoid in ensuring vascular safety, monitoring for complications, and supporting recovery in immediate postoperative cardiac catheterization care.

Choice B reason: Assessing peripheral pulses every 15 minutes post-femoral catheterization monitors for arterial occlusion or bleeding, critical for detecting complications like hematoma or thrombosis. This ensures timely intervention, essential for vascular integrity, preventing limb ischemia, and supporting safe recovery in the immediate postoperative period.

Choice C reason: Changing the dressing 4 hours post-catheterization is premature unless soiled; initial monitoring of pulses is priority. Assuming dressing change is urgent risks disrupting the site, increasing bleeding, critical to avoid in ensuring site stability and vascular safety in immediate post-catheterization care.

Choice D reason: Flexing the right knee is contraindicated post-femoral catheterization, risking site disruption or bleeding; leg immobility is required. Assessing pulses is key. Instructing flexion risks hematoma, critical to prevent in ensuring vascular safety, monitoring complications, and supporting recovery in postoperative cardiac catheterization clients.

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A nurse is assessing a client who received a Mantoux skin test 72 hours ago for tuberculosis screening. Which of the following findings indicates a positive test result?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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