A nurse is caring for a client who has a terminal illness. The client states, "I am not giving up. I want as much treatment as possible." Which of the following responses should the nurse make?

A. Whisper a series of words softly into one ear.

Explanation: Whispering words into one ear is not part of Weber's test. This action is more relevant to the assessment of hearing acuity and not the lateralization of sound. Weber's test focuses on the perception of sound in relation to both ears, not the ability to hear whispered words.

B. Place an activated tuning fork in the middle of the client's forehead.

Explanation: In Weber's test, a tuning fork is placed in the middle of the client's forehead. The test is designed to assess whether sound lateralizes (moves) to one ear or is heard equally in both ears. If the client perceives the sound more in one ear than the other, it may indicate a hearing imbalance or issue.

C. Deliver a series of high-pitched sounds at random intervals.

Explanation: Delivering high-pitched sounds at random intervals is not part of Weber's test. Weber's test involves a single action – placing an activated tuning fork in the middle of the client's forehead. The purpose is to determine if the client perceives the sound equally in both ears or if there is lateralization. Random intervals and high-pitched sounds are not specified components of this test.

D. Hold an activated tuning fork against the client's mastoid process.

Explanation: While holding a tuning fork against the mastoid process is part of another hearing test called the Rinne test, it is not the appropriate action for the Weber's test. The Rinne test compares air conduction (using the tuning fork near the ear) to bone conduction (using the tuning fork against the mastoid process) to evaluate hearing in each ear. In Weber's test, we are specifically interested in lateralization of sound, not comparing air and bone conduction.

A. Request that another nurse check the client's BP in 30 min:

Waiting for 30 minutes to have another nurse check the blood pressure may not be the most immediate and effective action. If there are concerns about the accuracy of the reading, rechecking the BP in the other arm promptly is a more appropriate and efficient approach.

B. Reposition the client supine and recheck her BP:

Repositioning the client supine is not necessary in this context. Blood pressure can be accurately measured while the client is sitting. Changing the position might not provide relevant information about the accuracy of the blood pressure reading.

C. Recheck the client's BP in her other arm for comparison:

This is the appropriate action. Checking the blood pressure in the other arm can help determine if there is a significant difference between the arms. A significant difference could indicate arterial disease or other issues. It's essential to confirm the accuracy of the blood pressure measurement.

D. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference:

While ensuring the appropriate size of the BP cuff is essential for accurate readings, this option is not directly addressing the current situation of an elevated blood pressure reading. Checking the other arm for comparison is more relevant to assess the accuracy of the measurement.