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: Bed rest for 24 hours post-surgery increases stasis, risking thrombosis; range-of-motion exercises promote circulation. Assuming bed rest is correct risks complications, critical to avoid in ensuring active circulation and preventing venous thromboembolism in postoperative clients during recovery.

Choice B reason: Placing a pillow under knees promotes venous pooling, increasing clot risk; range-of-motion exercises are safer. Assuming pillow use is correct risks impaired circulation, critical to prevent in ensuring effective postoperative care and reducing thrombosis risk in surgical clients.

Choice C reason: Incentive spirometry prevents respiratory complications, not directly promoting circulation; range-of-motion exercises are key. Assuming spirometry aids circulation risks overlooking mobility needs, critical to avoid in ensuring proper venous return and clot prevention in postoperative clients during recovery.

Choice D reason: Range-of-motion exercises promote circulation post-surgery, preventing venous stasis and thrombosis, critical for recovery. This instruction ensures active blood flow, essential for reducing clot risk, supporting healing, and enhancing postoperative outcomes in clients across various surgical procedures.

A. Supervise return demonstration of diaphragm use. B. Determine the client’s knowledge about diaphragm use. C. Teach the client how to insert the diaphragm. D. Document the client’s level of understanding about potential adverse effects.

Correct Answer is B

Explanation

Choice A reason: Supervising return demonstration follows teaching, not initial assessment; determining knowledge is first. Assuming demonstration is the first step risks ineffective education, potentially leading to misuse, critical to avoid in ensuring proper diaphragm use and contraception efficacy for female clients.

Choice B reason: Determining the client’s knowledge about diaphragm use is the first step, guiding tailored education and ensuring effective use. This assessment is critical for addressing gaps, promoting adherence, preventing contraceptive failure, and supporting informed decision-making in female clients requesting diaphragms for contraception.

Choice C reason: Teaching insertion follows assessing knowledge, which identifies educational needs. Assuming teaching is first risks overlooking client understanding, potentially leading to incorrect use, critical to prevent in ensuring effective diaphragm contraception and client safety in reproductive health care.

Choice D reason: Documenting understanding is a later step after assessing and teaching; determining knowledge is priority. Assuming documentation is first risks premature recording, potentially missing educational needs, critical to avoid in ensuring comprehensive diaphragm education and effective contraception for female 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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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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