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A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?

A reddened area measuring 10 mm

A reddened area measuring 5 mm

An induration measuring 5 mm

An induration measuring 10 mm

Answer and Explanation

The Correct Answer is D

A. A reddened area without induration is not a positive result.

B. A reddened area without induration is not considered positive.

C. An induration of 5 mm is positive only for high-risk groups (e.g., immunocompromised clients).

D. An induration measuring 10 mm is considered positive in most adults, indicating TB exposure.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Confusion is a key symptom of hypoglycemia due to the brain's lack of glucose.

B. Acetone breath is associated with diabetic ketoacidosis (DKA), a hyperglycemic state.

C. Polydipsia (increased thirst) is a sign of hyperglycemia, not hypoglycemia.

D. Hot, dry skin is a sign of hyperglycemia or dehydration.

A. Speak in a normal voice at a natural pace. B. Pause in the middle of sentences. C. Direct statements to the interpreter. D. Use gestures when speaking with the client.

Correct Answer is A

Explanation

A. Speak in a normal voice at a natural pace: This allows the interpreter to accurately convey the nurse's message without confusion or misinterpretation. Speaking slowly or loudly is unnecessary and can be perceived as disrespectful.

B. Pause in the middle of sentences: Pausing mid-sentence may result in incomplete or confusing information being relayed to the client.

C. Direct statements to the interpreter: The nurse should direct communication to the client to maintain engagement and respect.

D. Use gestures when speaking with the client: Gestures can be misinterpreted, and relying on them reduces clear verbal communication.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not.. I found the title to the car today, signed over to me.
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom. Client reports not wanting to eat anymore. Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has type 1 diabetes mellitus and was. Which of the following clients should the nurse instruct the staff to indicates that the client might be experiencing hypoglycemia?

Correct Answer is A

Explanation

A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter?

Correct Answer is A

Explanation

A nurse is caring for a client on an acute mental health unit. Exhibits Complete the following sentence by using the list of options. The nurse should delegate the client's ____________ and focus on _________

A nurse is caring for a client in an outpatient clinic. Exhibits Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep.

A nurse is assessing the grief response of a client whose child died 6 months ago. Which of the following client statements should the nurse report to the provider as an indication of major depressive disorder?

A nurse is reviewing the medical history of a client who asks about the use of warfarin. The nurse should identify which of the following findings as a contraindication for the administration of this medication?

A nurse is assessing the coping strategies of a client who has recently retired. Which of the following statements by the client indicates that the client is using compensation as a defense mechanism?

A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?