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 {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
Rationale for correct choices:
• Reye’s syndrome is a rare but serious condition that can develop after a viral illness when aspirin is given to children. The toddler’s symptoms—lethargy, persistent vomiting, and difficulty rousing—align with signs of increased intracranial pressure associated with Reye’s syndrome.
• Aspirin administration during a recent influenza A infection is a known trigger for Reye’s syndrome, as it can cause acute encephalopathy and liver dysfunction in pediatric patients.
Rationale for incorrect choices:
• Bronchitis would present with prominent lower respiratory symptoms such as productive cough, wheezing, and abnormal lung sounds, which are not noted here.
• Gastroenteritis is characterized by vomiting and diarrhea with signs of dehydration; this child has no diarrhea, and the neurological decline suggests CNS involvement rather than a purely GI process.
• Acetaminophen administration is not linked to Reye’s syndrome; toxicity causes liver injury but does not present with acute encephalopathy following viral illness in the same way.
• Cough finding is unrelated to the primary cause of the neurological changes and persistent vomiting; the cough has been present but is not the trigger for the current complication.
Correct Answer is B
Explanation
Rationale:
A. Perform an ECG every 12 hr: Frequent ECGs are typically done during the acute phase to monitor for arrhythmias, but by day 3 post-MI, continuous or as-needed monitoring is more appropriate unless new symptoms occur.
B. Obtain a cardiac rehabilitation consultation: Early involvement of cardiac rehab supports gradual activity progression, lifestyle modification, and psychosocial support, improving long-term outcomes after MI.
C. Draw a troponin level every 4 hr: Troponin testing is most useful for diagnosing and trending damage during the first 24 hours; by day 3, levels have usually peaked and are declining.
D. Place the client in a supine position while resting: Supine positioning can increase cardiac workload; a semi-Fowler's position is preferred to reduce venous return and ease breathing.
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