A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?
Deliver a series of high-pitched sounds at random intervals.
Hold an activated tuning fork against the client's mastoid process.
Whisper a series of words softly into one ear.
Place an activated tuning fork in the middle of the client's forehead.
The Correct Answer is D
Place an activated tuning fork in the middle of the client's forehead. The rationale for this answer is that Weber's test is used to assess for conductive or sensorineural hearing loss by comparing bone conduction in both ears. The nurse places an activated tuning fork in the middle of the client's forehead and asks if the sound is heard equally in both ears or louder in one ear.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A total laryngectomy is a surgical procedure that removes the entire larynx (voice box) and separates the airway from the mouth, nose and esophagus. The client will have a permanent tracheostomy (an opening in the neck) and will not be able to speak normally. An artificial larynx is a device that produces sound by vibrating against the neck or cheek and allows the client to communicate orally. The nurse's priority intervention is to review the use of an artificial larynx with the client before surgery to facilitate postoperative communication and reduce anxiety.
Correct Answer is A
Explanation
Cheyne-Stokes respirations are an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes. This type of breathing may occur in people who are dying due to heart failure, stroke, brain injury or other causes. The nurse should expect to observe irregular respirations with frequent periods of apnea in the client who is dying and having Cheyne-Stokes respirations.
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