Question

A spouse of a client with pulmonary tuberculosis (TB) receives a tuberculin skin test. The nurse reads the test and identifies an area of induration greater than 10 mm. What does this result indicate to the nurse?

1. No further action is required.
2. Additional tests are necessary.
3. Repeating the skin test is indicated.
4. Results are positive, indicating infection.

Answer 1

A tuberculin skin test showing an induration greater than 10 mm indicates a positive response, meaning the person has been exposed to TB. Further tests, such as a chest radiograph, are necessary to confirm active disease. A false-positive can occur in those vaccinated with the BCG vaccine.

Step-by-step explanation:

The client's spouse received a tuberculin skin test, which is a medical procedure used to detect exposure to tuberculosis. An area of induration greater than 10 mm typically indicates a positive test, suggesting that the person has been exposed to Mycobacterium tuberculosis and has developed an immune response. However, it does not confirm active disease. Therefore, this result would lead the nurse to item 4: Results are positive, indicating infection. This does not necessarily mean the individual has active TB, but it does warrant further investigation, including additional tests such as a chest radiograph to confirm the presence of an active infection.

It is important to note that individuals who have been vaccinated with the BCG vaccine may exhibit a false-positive result. In regions where BCG vaccinations are common, this can impact the usefulness of the test. Despite this, the tuberculin skin test remains an important tool for TB screening, especially when evaluating potential exposures like that of the client's spouse.