A nurse is preparing a client for intradermal tuberculin skin testing (TST). Which of the following statements should the nurse make?

“An indurated area of 4 millimeters indicates a positive result.”.

“The injection site will be evaluated within 24 hours.”.

“A positive result does not always indicate active disease.”.

“The test will not be administered if you have had a previous negative result.”. .

Answer and Explanation

The Correct Answer is C

Choice A rationale
An indurated area of 4 millimeters is not considered a positive result for tuberculin skin testing. The size of induration considered positive varies based on the individual’s risk factors and health status.
Choice B rationale
The injection site for a tuberculin skin test should be evaluated between 48 and 72 hours after administration, not within 24 hours. Evaluating it too early may not provide accurate results.
Choice C rationale

A positive result in a tuberculin skin test indicates that the person has been infected with TB bacteria, but it does not necessarily mean they have active TB disease. Further tests are needed to determine if the disease is active.
Choice D rationale
A previous negative result does not preclude the administration of a new tuberculin skin test. Individuals can be retested if there is a new risk of exposure or if it is required for medical or occupational reasons.

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Correct Answer is B

Explanation

Choice A rationale
Type 2 diabetes is characterized by insulin resistance, not the overproduction of insulin. Over time, the pancreas may produce less insulin, but the primary issue is the body’s inability to use insulin effectively.

Choice B rationale
Type 2 diabetes involves the body’s inability to process glucose properly due to insulin resistance. This leads to elevated blood glucose levels and various complications if not managed effectively.
Choice C rationale
Hemoglobin binding to sugar is related to the measurement of HbA1c, which reflects average blood glucose levels over time. It is not a cause of type 2 diabetes.
Choice D rationale
The destruction of pancreatic cells is a characteristic of type 1 diabetes, an autoimmune condition. Type 2 diabetes is primarily due to insulin resistance and is not caused by an autoimmune response.

A. Cheyne-Stokes breathing. B. Malignant hypertension. C. Acetone odor to breath. D. Blood glucose level below 40 mg/dL.

Correct Answer is C

Explanation

Choice A rationale
Cheyne-Stokes breathing is characterized by a pattern of periodic breathing with cycles of increasing and decreasing tidal volumes separated by periods of apnea. It is not typically associated with diabetic ketoacidosis (DKA) but rather with conditions such as heart failure, stroke, or brain injury.

Choice B rationale
Malignant hypertension is a severe form of high blood pressure that can lead to organ damage. It is not a typical finding in diabetic ketoacidosis. DKA is more commonly associated with dehydration, electrolyte imbalances, and metabolic acidosis.
Choice C rationale
An acetone odor to the breath is a classic sign of diabetic ketoacidosis. This occurs due to the accumulation of ketones in the blood, which are byproducts of fat metabolism when the body is unable to use glucose for energy.
Choice D rationale
Blood glucose levels below 40 mg/dL indicate hypoglycemia, not diabetic ketoacidosis. DKA is characterized by high blood glucose levels, typically above 250 mg/dL34.

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A nurse is preparing a client for intradermal tuberculin skin testing (TST). Which of the following statements should the nurse make?

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Naxlex Comprehensive Predictor Exams

An adult client newly diagnosed with type 2 diabetes mellitus asks a nurse to explain how he developed the condition. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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