Rule Out Tuberculosis

A nurse on a medical-surgical unit is caring for a 50-year-old male client newly admitted with a diagnosis of rule-out tuberculosis.

Which of the following findings should the nurse report to the provider? Select all that apply.

Choice A rationale

An absolute neutrophil count (ANC) less than 1,000/mm³ indicates neutropenia, which significantly increases the risk of infection. Limiting visitors to healthy adults minimizes exposure to pathogens that could be carried by individuals who are ill or immunocompromised, thereby reducing the risk of opportunistic infections.

Choice B rationale

Taking a rectal temperature is contraindicated in neutropenic clients due to the risk of introducing bacteria from the rectum into the bloodstream, which could lead to bacteremia or sepsis. Oral or axillary temperatures are preferred methods for temperature assessment in immunocompromised individuals to prevent mucosal trauma.

Choice C rationale

Increasing raw produce in the client's diet is contraindicated in neutropenic clients. Uncooked fruits and vegetables can harbor bacteria and fungi that, while usually harmless to individuals with intact immune systems, can cause severe infections in immunocompromised patients due to compromised gut mucosal barriers.

Choice D rationale

Instructing the client to floss his teeth daily is contraindicated in severe neutropenia. Flossing can cause micro-abrasions and bleeding of the gingiva, creating entry points for oral bacteria into the bloodstream, which can lead to systemic infections in a client with a severely compromised immune system.

Choice A rationale: Yellow sclera indicates jaundice, a clinical sign of elevated bilirubin caused by hepatocellular damage. Isoniazid and rifampin are both hepatotoxic drugs commonly used in tuberculosis treatment. When the liver is compromised, bilirubin accumulates and is deposited in the sclera and skin. This clinical presentation requires immediate provider notification, as it may indicate early liver failure or the need to discontinue hepatotoxic medications to prevent worsening hepatic injury.

Choice B rationale: The AST level has increased from 35 to 36 units/L, reaching the upper limit of normal. Normal AST is 0–35 units/L. Although this is a slight increase, in the context of tuberculosis treatment with known hepatotoxic medications like isoniazid and rifampin, even a small upward trend can be an early warning of hepatic injury. Hepatotoxicity can progress rapidly, so any increase warrants provider notification for monitoring or possible medication adjustment.

Choice C rationale: The 3.2 kg (7 lb) weight loss is a classic symptom of tuberculosis due to increased metabolic demand and decreased appetite from systemic inflammation. However, this weight loss is already known and part of the client's initial presentation, not a new or worsening symptom. It does not require immediate provider notification unless the weight loss continues to progress or is accompanied by other signs of deterioration such as hypotension or electrolyte imbalance.

Choice D rationale: The Mantoux test showed a 12 mm induration, which is considered positive in individuals with risk factors like recent travel or suggestive radiographic findings. However, a positive Mantoux alone is not urgent, especially when TB has already been suspected and treatment has been initiated. It confirms exposure but does not require immediate provider notification unless being used for new diagnosis initiation. The result is consistent with the working diagnosis of tuberculosis.

Choice E rationale: ALT increased from 36 to 38 SI/L, exceeding the upper limit of normal (4–36 SI/L). ALT is a liver-specific enzyme, and its elevation strongly suggests hepatocellular injury. Both isoniazid and rifampin are known to elevate ALT levels. Even a minor elevation in ALT in this context may be the beginning of drug-induced hepatitis, which can progress without early intervention. Prompt reporting is needed to assess medication risks and protect liver function.

Choice F rationale: Reddish-orange urine is a well-documented, harmless side effect of rifampin. This medication binds to chromophores and imparts a discoloration to urine, sweat, tears, and saliva. It is not a sign of renal dysfunction or drug toxicity. Patient education on this harmless but expected effect is important, but it does not require provider notification. Misinterpretation may cause alarm, but the discoloration is entirely benign and anticipated during rifampin therapy.