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.
Place an activated tuning fork in the middle of the client's forehead.
Hold an activated tuning fork against the client's mastoid process.
Whisper a series of words softly into one ear.
The Correct Answer is B
A. Delivering a series of high-pitched sounds at random intervals is not related to the Weber's test.
B. Weber's test is performed by striking the tuning fork and placing it against the middle of the forehead. Ask the patient if the tone is equal in both ears. Diminution in the affected ear indicates sensorineural hearing loss.
C. Placing an activated tuning fork on the client's mastoid process is not part of the Weber's test.
D. Whispering a series of words softly into one ear is unrelated to the Weber's test; it's a test for assessing auditory acuity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Allowing space for three fingers is not a standard practice for tracheostomy ties. The ties should be snug but not overly tight, typically allowing for one or two fingers’ width to ensure proper fit and comfort.
B. A quick-release knot is not typically used for securing tracheostomy ties for safety reasons.
C. Extending the client's neck while securing the ties could cause discomfort and is not necessary.
D. This is the safest method to prevent accidental dislodgement of the tracheostomy tube. By securing the new ties first, the tracheostomy tube remains in place, reducing the risk of complications.
Correct Answer is C
Explanation
A. Expressing a desire for independence indicates the client may not have fully adapted to relying on others yet.
B. Reluctance to ask for help suggests the client is still adjusting and may not have fully embraced the new living arrangement.
C. Expressing enjoyment or appreciation for others cooking for them indicates acceptance of assistance and adaptation to the new living situation.
D. Expressing uncertainty about daily activities suggests a lack of adjustment to the new environment and situation.
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