The nurse administers a tuberculin screening test to a patient who has no known risk factors for tuberculosis. When the test site is read 48 hours later, which result is considered positive?
a. Induration of 2 mm or more
b. Induration of 5 mm or more
c. Induration of 10 mm or more
d. Induration of 15 mm or more
D
A raised, reddened, or hard zone around the test site indicates a positive tuberculin skin test. An induration of 15 mm or more indicates a positive reaction in patients with no known risk factors for TB. An induration that measures 5 mm or more in diameter indicates a positive TB reaction in patients who are human immunodeficiency virus (HIV) positive, have fibrotic changes on chest radiograph consistent with previous TB infection, have had organ transplants, or are immunosuppressed. An induration of 10 mm or more indicates a positive TB reaction in patients who are recent immigrants; injection drug users; residents and employees in high-risk settings; patients with certain chronic illnesses; children younger than 4 years of age; and infants, children, and adolescents exposed to high-risk adults.
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The patient has been diagnosed with multiple sclerosis, a disease that reduces the amount of available adenosine triphosphate (ATP) in the body
The nurse recognizes that this reduction in ATP is caused by the impact of the disease on what part of the cell? A) Cell neuron B) Endoplasmic reticulum C) Golgi bodies D) Mitochondria
As a nurse prepares to leave a room he says to his client, "Please let me know if there is anything I can do to help you." Which therapeutic technique does this reflect?
A) Offering self B) Broad openings C) General leads D) Making stereotyped comments
A nurse suspects that a patient being admitted for outpatient surgery may have a history of alcohol abuse. To further assess this issue, the nurse should consider:
a. using a screening tool, such as AUDIT-C to assess the extent of the abuse. b. asking directly if the patient has ever had problems with abusing alcohol. c. interviewing the family because the patient is likely to deny having a problem. d. addressing the suspicion before discharge since it has no direct effect on the patient's surgery.
An infant was born with hemolytic disease of the fetus and newborn (HDFN). What treatment does the healthcare professional anticipate for this baby?
a. Administration of intravenous fluids to dilute the blood b. Replacement transfusion of Rh-positive blood not contaminated with anti-Rh antibodies c. Performance of a splenectomy to prevent the destruction of abnormal erythrocytes d. Replacement transfusion of Rh-negative erythrocytes