A patient, diagnosed with malnutrition, had an intradermal tuberculin skin test 3 days ago. The site is currently showing no signs of induration. The nurse realizes this finding would indicate which of the following?
1. no exposure to tuberculosis
2. an intact immune system
3. the test needs to be repeated
4. anergy
4
Rationale: Cell-mediated immunity is one of the body's defense mechanisms that is most affected by malnutrition. Skin testing is a simple method for evaluating cell-mediated immunity status. A test dose of a known antigen, such as tuberculin, is administered intradermally. The patient's ability to respond to this immunologic challenge is evaluated 24 and 48 hours after administration. If cellular immunity is intact, an induration of 2 to 5 mm should be observed at the injection site. If no skin reaction occurs, the patient is considered to be anergic, which means that cellular immunity may have been negatively affected by malnutrition. The results of this test do not indicate that the patient has had no exposure to tuberculosis. The results of this test do not indicate that the patient has an intact immune system. The test does not need to be repeated.
You might also like to view...
A client has been placed on Contact Precautions. The client's family is very afraid to visit for fear of being "contaminated" by the client. What action by the nurse is best?
a. Explain to them that these precautions are mandated by law. b. Inform them that the infection is the issue, not the client. c. Reassure the family that they will not get the infection. d. Tell the family it is important that they visit the client.
Which nursing intervention helps promote stress reduction and healthy coping in a patient diagnosed with a dissociative disorder?
1. Perform safety checks at each health care interaction. 2. Discuss activities that patients can do that eliminate the need for safety provisions. 3. Review the patient's daily personal journal to assess appetite. 4. Teach nonpharmacologic strategies for reducing pain.
The nursing staff is admitting a client diagnosed with diabetic ketoacidosis (DKA). The LPN asks the RN if the pulse oximeter needs to be placed on the client. What is the nurse's best response to the LPN?
1. "Please place the pulse oximeter on the client." 2. "I will let you know after I complete my assessment." 3. "Thanks, but that is something I have to do for the client." 4. "We don't have an order to do that."
Schizophrenia is a mood disorder
True False