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.
Whisper a series of words softly into one ear.
Place an activated tuning fork in the middle of the client's forehead.
Hold an activated tuning fork against the client's mastoid process.
The Correct Answer is C
C. This procedure helps assess the conduction of sound through bone to both ears, which can indicate whether hearing loss is conductive or sensorineural. The sound should be heard equally in both ears if hearing is normal. If there is unilateral hearing loss, the sound will be heard better in one ear.
A. Not part of the weber’s test
B. Not part of the weber’s test D. Described the Rinne’s test
Nursing Test Bank
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Related Questions
Correct Answer is C
Explanation
C. This finding suggests a swallowing difficulty (dysphagia), which is a significant concern for clients with left-sided weakness following a stroke. Dysphagia increases the risk of aspiration, choking, and pneumonia. Immediate intervention is necessary to prevent complications and ensure safe oral intake.
A. While elevated blood pressure may be a concern for a client with a history of stroke, it is not the priority finding in this scenario unless it is significantly high or symptomatic. The immediate priority is addressing issues related to the client's physical function and safety.
B. Malnutrition and dehydration are common risks for clients with left-sided weakness following a stroke. Ensuring adequate nutrition and hydration is essential for promoting recovery and preventing complications such as pressure ulcers and infections.
D. While leaning to one side may indicate asymmetrical weakness or impaired balance, it is not the priority finding compared to issues related to nutrition, swallowing safety, and blood pressure control.
Correct Answer is D
Explanation
D. Demonstrates the nurse's commitment to advocating for the client's wishes and ensuring that their preferences are communicated to the healthcare provider. This response acknowledges the client's desire for ongoing treatment while also facilitating further discussion with the healthcare team about the available options and potential treatment modalities.
A. This may be premature and could be perceived as dismissive of the client's wishes. While hospice care may be appropriate for some clients with terminal illnesses, it should be introduced as an option after thorough discussion and consideration of the client's preferences and goals of care.
B. This may be blunt and insensitive, potentially causing distress or anxiety for the client. It is important to provide information about prognosis in a sensitive and empathetic manner, taking into account the client's emotional state and readiness to discuss such matters.
C. This may overlook the client's desire for continued treatment and may not fully address their concerns or needs. While encouraging the client to focus on quality of life and personal fulfillment is important, it should be done in conjunction with discussions about treatment options and goals of care.
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