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.

Answer and Explanation

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

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Correct Answer is A

Explanation

A. Acute hemolytic:
Acute hemolytic transfusion reactions typically present with symptoms such as fever, chills, flank pain, hemoglobinuria (blood in the urine), and possibly hypotension. This occurs due to the rapid destruction of transfused red blood cells, often because of ABO incompatibility between the donor and recipient. The symptoms described in the scenario, including chest tightness, are not consistent with acute hemolytic reactions.

B. Allergic:
Allergic reactions to blood transfusions can manifest with symptoms such as itching, hives, flushing, and mild respiratory distress. While headache and low-back pain can occur in allergic reactions, the feeling of "tightness" in the chest is more indicative of another type of reaction.

C. Bacterial:
Bacterial contamination of blood products can lead to transfusion-related sepsis. Symptoms may include fever, chills, hypotension, and rapid onset of shock. However, the presence of headache and low-back pain, along with chest tightness, is not typically associated with bacterial contamination.

D. Febrile nonhemolytic:
Febrile nonhemolytic transfusion reactions are characterized by fever, chills, and rigors. While fever and chills are common symptoms, they do not typically cause chest tightness or low-back pain.

A. Cover the cord with the upper edge of the diaper. B. Apply petroleum jelly around the cord with every diaper change. C. Report minor bleeding when the cord's stump falls off. D. Wash the area around the base of the cord with water.

Correct Answer is D

Explanation

A. Cover the cord with the upper edge of the diaper: Placing the diaper below the umbilical cord stump allows air to circulate around the area, promoting drying and preventing irritation. Covering the cord stump with the upper edge of the diaper may trap moisture and increase the risk of infection.
B. Apply petroleum jelly around the cord with every diaper change: Applying petroleum jelly or any other substance to the umbilical cord stump is not recommended as it can interfere with the natural drying process. Keeping the area dry promotes quicker healing and reduces the risk of infection.
C. Report minor bleeding when the cord's stump falls off: It is normal for a small amount of bleeding to occur when the umbilical cord stump falls off. However, ongoing bleeding or excessive bleeding should be reported to the healthcare provider. Reporting minor bleeding when the stump falls off is unnecessary as it is considered a normal part of the healing process.
D. Wash the area around the base of the cord with water: Cleaning the area around the base of the cord with water helps to prevent infection and promotes healing. It is essential to keep the area clean and dry to avoid bacterial growth. Using water alone is sufficient for cleansing, and there is no need to use soap or other products that may irritate the delicate skin.

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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?

Nursing Test Bank

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