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. Loosening the bed linensmay not have a significant effect on the client's pain level, and may increase the risk of infection or further injury to the pressure ulcer.
B. Massaging the sacrum in the context of a pressure injury might exacerbate the condition and isn't recommended.
C. Providing bright lights might not specifically address the acute pain from the pressure injury.
D. Music therapy is a nonpharmacological intervention that can help reduce pain perception, anxiety, and stress in clients who have acute pain. Music can also provide distraction, relaxation, and comfort to the client.

A. Elevate full-length side rails on both sides of the client's bed. B. Place the bedside table 0.9 m (3 feet) away from the bed. C. Provide the client with a night light. D. Keep the client's room temperature at 18° C (64.4" F).

Correct Answer is C

Explanation

A. Elevating full-length side rails on both sides of the client's bed is not recommended, as it can increase the risk of injury if the client tries to climb over them or gets trapped between them.

B. Placing the bedside table 0.9 m away is unrelated to fall prevention.
C. A night light can help the client see better in the dark and avoid tripping or falling over objects.
D. Maintaining the room temperature is important for comfort but doesn't directly prevent falls.

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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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