A school nurse is using the Weber's test to check a child's hearing acuity. Which of the following actions should the nurse take?
Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears.
Measure the amount of time the child can hear the sound.
Obtain a tympanogram reading prior to initiating the test.
Place a vibrating tuning fork on the top of the child's head.
The Correct Answer is D
A. Holding a vibrating tuning fork 1 to 2 cm from the child's ears is not a part of the Weber's test procedure. The Weber's test involves assessing lateralization of sound in cases of unilateral hearing loss. Placing the tuning fork close to the ears may interfere with the accuracy of the test.
B. Measuring the amount of time the child can hear the sound is not relevant to the Weber's test. This action does not assess lateralization of sound but rather evaluates the duration of hearing.
C. Obtaining a tympanogram reading is not necessary before initiating the Weber's test. Tympanometry is a separate test used to assess the function of the middle ear, particularly the movement of the eardrum and the conduction bones.
D. Placing a vibrating tuning fork on the top of the child's head is the correct action for performing the Weber's test. During this test, the nurse activates a tuning fork and places it on the midline of the child's head or forehead. The child is asked if they hear the sound equally in both ears or if it is louder in one ear than the other. This helps determine if there is asymmetrical hearing loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Measure the legs with a tape measure to determine stocking size: Antiembolic stockings should fit properly to provide therapeutic compression without causing discomfort or impairing circulation. Measuring the legs accurately with a tape measure ensures the stockings fit appropriately and exert the correct amount of pressure to prevent deep vein thrombosis (DVT) and promote venous return.
B. Remove the stockings every 24 hr: Antiembolic stockings are typically worn continuously, especially during periods of immobility, to maintain consistent compression and prevent blood clots. Removing the stockings every 24 hours would interrupt the therapeutic effect and increase the client's risk of developing DVT.
C. Massage the legs before applying the stockings: Massaging the legs before applying antiembolic stockings is contraindicated, as it can dislodge blood clots and increase the risk of embolism. Additionally, massaging may cause trauma to the skin and exacerbate any existing circulatory issues.
D. Fold the stockings at the top if they are too long: Folding the stockings at the top if they are too long can create pressure points and compromise circulation, leading to discomfort and potentially exacerbating vascular issues. It is essential to ensure the stockings fit properly by selecting the appropriate size rather than folding them.
Correct Answer is B
Explanation
A. "A health care surrogate must be a family member.": This statement is incorrect. A health care surrogate, also known as a health care proxy or agent, does not necessarily have to be a family member. It can be any individual chosen by the client to make health care decisions on their behalf if they become unable to do so.
B. "The client can resume control of health care after a temporary loss of competency.": This statement demonstrates an understanding of advance directives. Advance directives allow individuals to maintain control over their health care decisions by specifying their preferences for treatment or appointing a surrogate decision-maker. If a client experiences a temporary loss of competency, they can regain control of their health care decisions once competency is restored.
C. "The provider will choose a client's health care surrogate.": This statement is incorrect. It is the responsibility of the client to choose their health care surrogate. While healthcare providers may provide guidance and information about advance directives, they do not choose the surrogate for the client.
D. "The provider can go against the client's wishes regarding advance directives.": This statement is incorrect. Advance directives are legally binding documents that express a client's wishes regarding medical treatment. Healthcare providers are generally obligated to follow the directives outlined in these documents, and they cannot go against the client's wishes unless certain legal exceptions apply, such as emergency situations where immediate action is required to preserve life.
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