A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?

Whisper a series of words softly into one ear.

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

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

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

Answer and Explanation

The Correct Answer is B

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.

Solved] In Weber's test, lateralization of sound to diseased ear

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Correct Answer is B

Explanation

A. Use an 18-gauge, 1-inch needle to administer the medication.An 18-gauge needle is too large for subcutaneous heparin injections, which require a smaller, finer needle, typically 25- to 27-gauge and ⅜- to ⅝-inch in length. The smaller gauge reduces discomfort and is appropriate for subcutaneous tissue.

B. Inject 5.1 cm (2 in) away from the umbilicus.Heparin injections should be given at least 2 inches from the umbilicus to avoid areas with dense blood vessels, which decreases the risk of hematoma formation and improves medication absorption.

C. Expel air bubble before injecting medication.For prefilled heparin syringes, the small air bubble should not be expelled, as it helps ensure the full dose is administered and can reduce bruising by sealing the medication in the tissue.

D. Massage the injection site after withdrawing the needle.Massaging the site after a heparin injection is not recommended as it increases the risk of bruising and tissue irritation. Instead, gentle pressure may be applied briefly if there is bleeding at the site.

A. The nurse's empathy about the client having to self-inject B. The client seeking family approval by agreeing to a teaching plan C. The nurse explaining the need for education to the client D. The client's belief that his needs will be met through education

Correct Answer is D

Explanation

A. The nurse's empathy about the client having to self-inject:

While empathy is important for building a therapeutic relationship, the client's motivation to learn is more likely to be influenced by factors directly related to their own needs and perceived benefits.

B. The client seeking family approval by agreeing to a teaching plan:

External factors, such as seeking family approval, may influence a client's willingness to participate in a teaching plan, but they might not be as effective in sustaining motivation over the long term. Intrinsic motivation tends to be more enduring and impactful.

C. The nurse explaining the need for education to the client:

While explaining the need for education is important, the client's motivation may be more influenced by their personal beliefs about the benefits of learning and meeting their own needs rather than an external explanation.

D. The client's belief that his needs will be met through education:

This statement reflects the client's intrinsic motivation, where the client perceives that learning to self-administer daily low-dose heparin injections will meet his needs. Intrinsic motivation is a powerful driver for learning because it comes from within the individual.

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A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

Correct Answer is D

Explanation

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