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.
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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Related Questions
Correct Answer is B
Explanation
A. Leave resuscitation equipment and supplies at the bedside: This can be distressing for the family. Removing such equipment before the family views the body promotes a more peaceful environment.
B. Hold the client's eyelids closed until they remain shut: This is part of postmortem care to maintain a natural appearance. It shows respect and helps prepare the body before the family views it.
C. Apply identification tags to the client's extremities: While necessary, identification tagging is not a priority before the family views the body. It is typically done before transport to the morgue.
D. Keep the head of the bed flat: Elevating the head of the bed slightly helps prevent discoloration due to blood pooling and gives the body a more natural appearance. Keeping it flat is not ideal.
Correct Answer is C
Explanation
A. Show the client a video about self-administration of insulin: Watching a video is a passive learning that primarily engages the cognitive domain. It provides information but does not allow the client to practice hands-on skills, which are needed for psychomotor learning.
B. Assist the client in discussing their feelings about having diabetes mellitus: Discussing feelings pertains to the affective domain, which focuses on emotions, attitudes, and values. It does not involve physical skills or actions, so it is not psychomotor learning.
C. Observe the client practice self-monitoring of blood glucose levels: Psychomotor learning involves acquiring skills through practice and demonstration. Observing the client perform self-monitoring of blood glucose levels allows the nurse to assess their ability to carry out the task and refine the skill through repetition.
D. Ask the client to attend a class about following a diabetic diet: Attending a class is more aligned with the cognitive domain, where the focus is on gaining knowledge. This action does not involve practicing physical skills necessary for psychomotor learning.
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