A nurse is assessing a client who received a Mantoux skin test 72 hr ago for tuberculosis screening. Which of the following findings indicates a positive test result?
A blister-like area
A cool, blanched area
An elevated, hardened area
An area of ecchymosis
The Correct Answer is C
Rationale:
A. A blister-like area: Blistering is not the expected reaction used to interpret a Mantoux test. The result is based on the presence and size of induration, not the formation of blisters.
B. A cool, blanched area: Coolness and blanching are not indicators of a positive test. These findings may reflect poor circulation or local skin reaction unrelated to tuberculosis screening.
C. An elevated, hardened area: Induration (elevated, firm area) at the injection site, measured in millimeters, is the basis for determining a positive result. The size threshold for positivity depends on the client’s risk factors for tuberculosis.
D. An area of ecchymosis: Bruising at the site is a local skin reaction that can occur after any injection and is unrelated to the diagnostic criteria for a positive Mantoux test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Implement activities that promote the client's self-esteem: While boosting self-esteem can support smoking cessation, it is not the first priority. The nurse must first assess the client’s current coping strategies to tailor the cessation plan.
B. Offer a list of smoking cessation support groups: Providing resources is helpful, but without assessing the client’s needs and coping methods first, the support may not be appropriately matched to the client’s situation.
C. Provide education about the dangers of smoking: Education is important, but most clients are already aware of the health risks. Effective teaching requires first understanding the client's motivation and coping mechanisms.
D. Determine the client's coping methods: Assessment is always the initial step in the nursing process. Identifying how the client currently manages stress will help the nurse create an individualized and effective cessation plan.
Correct Answer is ["A","D","E"]
Explanation
Rationale:
A. Limit visitors to 30 min per day: Time restrictions help reduce others’ exposure to radiation from the sealed implant. Limiting duration minimizes cumulative exposure for visitors while still allowing social interaction for the client.
B. Place the client in a semi-private room: Clients with internal radiation implants require a private room to protect others from unnecessary radiation exposure. A semi-private room increases the risk of radiation exposure to other patients and is inappropriate.
C. Instruct visitors who are pregnant to remain 3 feet from the client: Pregnant visitors should avoid contact with clients receiving internal radiation entirely, as even minimal exposure could harm the fetus. The safest recommendation is to avoid visiting during treatment.
D. Wear a lead apron when providing care: A lead apron shields the nurse from radiation exposure, especially when working close to the client. This is part of the time, distance, and shielding principles for radiation safety.
E. Close the door to the client's room: Keeping the door closed helps contain radiation within the client’s room, reducing exposure to staff and visitors in nearby areas. This is a standard precaution in caring for clients with sealed implants.
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