A patient who had a Mantoux test for tuberculosis 2 days ago has a 2 mm area of erythema at the site of the test. How should the nurse evaluate this result?
1. As negative
2. As positive for tuberculosis
3. As indicating a sputum test for acid-fast bacilli is needed
4. As indicating need for a repeat PPD
1
Rationale 1: The intradermal PPD or Mantoux test is read within 48 to 72 hours, the peak reaction period, and recorded as the diameter of induration (raised area, not erythema) in millimeters. The area on the patient is erythematous, not an induration. No follow-up is needed, as this patient's response is by definition a negative one.
Rationale 2: Mantoux is a screening test for exposure to, not presence of, the disease.
Rationale 3: A sputum test is not indicated at this time.
Rationale 4: The results do not indicate a second PPD is necessary.
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