A nurse is performing Weber's test for a client who has hearing loss. Which of the following actions should the nurse take?

Place a vibrating tuning fork against the midline vertex of the client's head.

Have the client repeat a phrase spoken by the nurse while the nurse's mouth is hidden.

Whisper words for the client to identify.

Ask the client to occlude one ear with a finger.

Answer and Explanation

The Correct Answer is A

A. Place a vibrating tuning fork against the midline vertex of the client's head: The Weber test is performed by placing a vibrating tuning fork on the midline of the client's forehead or vertex of the head. This tests for lateralization of sound, helping to distinguish between conductive and sensorineural hearing loss based on which ear hears the sound louder.

B. Have the client repeat a phrase spoken by the nurse while the nurse's mouth is hidden: This action refers to the "speech discrimination test" rather than the Weber test. It is not part of the Weber test, which is specifically used to assess the lateralization of sound.

C. Whisper words for the client to identify: This refers to a different hearing test, called the "whisper test," used to assess hearing ability, not the Weber test. The Weber test specifically uses a tuning fork to assess how sound is heard by the client.

D. Ask the client to occlude one ear with a finger: While blocking one ear can be used in other tests (like Rinne's test), it is not necessary for the Weber test, which involves placing the tuning fork in the center of the head.

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Correct Answer is B

Explanation

A. "I'm sure your family will be here soon.": While this response tries to reassure the client, it does not address the client’s current feelings or provide immediate support. It might also come across as dismissive since the nurse cannot be sure when the family will arrive.

B. "I will be available for you until your family arrives.": This response acknowledges the client’s anxiety and offers support in the meantime. It shows the nurse’s availability and commitment to making the client feel safe and supported while waiting for their family.

C. "Why do you think your family is delayed?": This question might make the client feel pressured or defensive and focuses on the delay rather than offering reassurance or emotional support. It does not directly address the client’s emotional needs.

D. "You'll feel better once this procedure is over.": While this response aims to reassure the client, it might minimize their current feelings of anxiety. It focuses on the future rather than addressing the immediate emotional needs of the client.

A. Projection B. Sublimination C. Rationalization D. Dissociation

Correct Answer is C

Explanation

A. Projection: Projection involves attributing one’s own undesirable feelings or thoughts onto others. This is not applicable here, as the client is not projecting their behavior onto someone else.

B. Sublimation: Sublimation is the process of channeling negative or unacceptable impulses into socially acceptable activities. Smoking due to anxiety is not an example of channeling impulses into a productive or acceptable activity.

C. Rationalization: Rationalization is a defense mechanism where a person justifies or makes excuses for their behavior or feelings. In this case, the client is justifying smoking as a way to manage anxiety, which is a classic example of rationalization.

D. Dissociation: Dissociation involves a detachment from reality or a separation of thoughts, identity, or consciousness, typically as a coping mechanism in response to trauma or stress. It is not applicable in this situation, where the client is not detaching from reality.

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A nurse is performing Weber's test for a client who has hearing loss. Which of the following actions should the nurse take?

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