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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Keep eyes open during relaxation therapy: Keeping the eyes closed is typically recommended during relaxation and meditation to help focus and avoid external distractions. Keeping the eyes open can interfere with the ability to achieve a relaxed state.

B. Tighten and relax muscles during relaxation therapy: Progressive muscle relaxation involves tightening and then relaxing each muscle group to help reduce tension and promote relaxation. This technique helps increase body awareness and alleviate stress.

C. Plan to meditate immediately after meals: Meditating immediately after meals can be uncomfortable because it may cause indigestion or distract from the relaxation process. It’s better to meditate when the stomach is not full to avoid discomfort.

D. Take short and shallow breaths when meditating: Deep and slow breathing is a key component of meditation and relaxation techniques. Short and shallow breaths can increase stress rather than reduce it, as they may activate the body's "fight or flight" response. Deep breathing helps activate the parasympathetic nervous system, which promotes relaxation.

A. Cilent rates pain as 8 on a scale of 0 to 10 in their left knee B. Client reports no relief with pain medications C. Left knee wound is 3 cm by 2 cm with 1 cm depth D. Wound bed vascular with some approximation of the edges E. Mild purulent drainage noted

Correct Answer is ["A","B","C","E"]

Explanation

Rationale:

Client rates pain as 8 on a scale of 0 to 10 in their left knee. Client reports no relief with pain medications. The client’s pain has worsened from 4/10 despite pain medication, indicating the current pain management approach is ineffective, and the wound may not be healing as expected.
Mild purulent drainage noted: The presence of purulent drainage is a sign of infection, further indicating that the wound vac therapy has not been successful in preventing or managing infection at the wound site.
Left knee wound is 3 cm by 2 cm with 1 cm depth, compared to 2 cm by 2 cm with 1 cm depth one week ago: The increase in wound sizefrom 2cm by 2 cm to 3 cm by 2 cm suggests that the wound vac therapy is not promoting healing effectively, leading to a failure of wound closure.

Rationale for Incorrect Choices:

Wound bed vascular with some approximation of the edges: The wound bed being vascular with some approximation of the edges indicates that there is some healthy tissue and the edges of the wound are coming together. This suggests that some healing is occurring, although it may be slower than expected.

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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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Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about meditation and progressive relaxation to reduce stress. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

Correct Answer is ["A","B","C","E"]

Explanation

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