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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Two-point alternating gait involves partial weight-bearing on both legs and wouldn’t suit a client who can bear weight on only one leg.
B. Four-point alternating gait involves walking by moving one crutch followed by the opposite leg and is not suitable for a person who can bear weight on just one leg.
C. Swing-through gait involves swinging both legs forward between the crutches, typically used for individuals who have little or no weight-bearing ability.
D. Three-point gait involves bearing weight on one leg while using crutches and moving the other leg forward, the most appropriate gait for someone who can bear weight on one leg.

A. "The scale measures six elements." B. "The client's age is part of the measurement." C. "The higher the score, the higher the pressure injury risk." D. "Each element has a range from one to five points."

Correct Answer is A

Explanation

A. The Braden scale does evaluate six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
B. The client's age isn't directly part of the Braden scale; it assesses various risk factors, but age isn't one of them.
C. In contrast, the lower the Braden scale score, the higher the risk of pressure injuries.
D. Each element in the Braden scale is rated on a scale from one to four or one to three, depending on the element, not from one to five points.

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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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