A patient with possible exposure to tuberculosis (TB)returns to a clinic 48 hours following an intradermal (Mantoux)test.How should the nurse determine the results of the Mantoux test?
A)Ask the patient to identify the area of pain around the injection site and record an approximate measure of that area.
B)Compare the area of erythema to the chart provided with the tuberculin injection and record the closest measurement.
C)Measure the area of redness around the intradermal site with a ruler and record "positive if more than 10 mm" or "negative if less than 10 mm."
D)Palpate the site of the injection and use a ruler to measure and record the largest diameter of induration.

Question

Quizplus · Accepted Answer

The correct method of interpreting the Mantoux test is to palpate the site of injection and use a ruler to measure the largest diameter of induration (not erythema). Erythema (redness) alone is not an adequate measure of a positive or negative reaction. The size of the induration is then used to determine the result, with a reaction of ≥10 mm generally considered positive in a patient with no known risk factors for TB.

A Patient with Possible Exposure to Tuberculosis (TB)returns to a Clinic