The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is important for the nurse to ask before the skin test?

Correct Answer: D

Rationale: Rationale: The correct answer is D. The BCG vaccine can cause a false-positive TB skin test result. Asking if the patient received the BCG vaccine is crucial to interpret the TB skin test accurately. If the patient received the BCG vaccine, the nurse should consider alternative diagnostic tests for TB. Incorrect choices: A: Asking about OTC medications is not directly related to the accuracy of the TB skin test. B: Family history of TB is important for assessing the patient's risk but does not impact the interpretation of the skin test. C: The duration of time since moving to the US may provide context but does not influence the TB skin test results.

Correct Answer: A

Rationale: The correct answer is A: Instruct the client to limit protein intake. Limiting protein intake is unnecessary for blood pressure control. Here's the rationale: 1. Sodium intake: Excessive salt intake can lead to high blood pressure, so teaching the client to avoid adding salt to foods is important. 2. Weight management: Excess weight can contribute to high blood pressure, so discussing weight reduction or maintenance is crucial. 3. Exercise: Regular physical activity can help lower blood pressure, making it important to stress the importance of an exercise program. 4. Protein intake: While a balanced diet is important for overall health, limiting protein intake specifically is not typically a key factor in blood pressure control.

Correct Answer: B

Rationale: The correct answer is B: Fatigue, confusion, and weakness. Hypercalcemia is characterized by high levels of calcium in the blood, leading to neurological symptoms like fatigue, confusion, and weakness. This occurs due to the effect of excess calcium on the nervous system. Choices A, C, and D are incorrect as hypertension and bradycardia are not typical manifestations of hypercalcemia, laboratory results of potassium and sodium levels do not specifically indicate hypercalcemia, and decreased urine output is not a typical symptom of hypercalcemia.

Correct Answer: C

Rationale: The correct answer is C: Autoimmune disorders. Raynaud's phenomenon is characterized by cold, numb fingers due to vasoconstriction of blood vessels in response to cold or stress. It is often associated with autoimmune disorders like lupus or scleroderma. Testing for autoimmune disorders may include antinuclear antibody (ANA) testing, rheumatoid factor (RF) testing, and specific autoantibody testing. Explanation for why the other choices are incorrect: A: Hyperglycemia is high blood sugar levels, which is not directly related to Raynaud's phenomenon. B: Hyperlipidemia is high levels of fats in the blood, which is not directly related to Raynaud's phenomenon. D: Coronary artery disease is a condition of the heart's blood vessels, and it is not directly related to Raynaud's phenomenon.

Correct Answer: C

Rationale: Step 1: Diltiazem is a calcium channel blocker. Step 2: Calcium channel blockers like diltiazem work by relaxing and dilating coronary arteries. Step 3: Coronary artery spasms are a characteristic feature of Prinzmetal's angina. Step 4: Therefore, the accurate action of diltiazem is to decrease coronary artery spasms. Summary: Choice A is incorrect because diltiazem does not directly reduce heart palpitations. Choice B is incorrect because diltiazem does not prevent coronary artery plaque. Choice D is incorrect because diltiazem does not increase the contractile force of the heart.