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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?

A.

Measure the amount of time the child can hear the sound.

B.

Obtain a tympanogram reading prior to initiating the test.

C.

Place a vibrating tuning fork on the top of the child's head.

D.

Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Measuring the amount of time the child can hear the sound is not the correct action when performing Weber's test. Weber's test is used to assess hearing acuity and lateralization. In this test, a vibrating tuning fork is placed in the middle of the patient's forehead, and the patient is asked if the sound is heard equally in both ears or if it is louder in one ear. This helps identify whether there is a conductive or sensorineural hearing loss. The duration of hearing the sound is not relevant to this test.

Choice B rationale:

Obtaining a tympanogram reading is not necessary before initiating Weber's test. Tympanometry assesses the movement of the eardrum in response to changes in air pressure and can help diagnose conditions like middle ear effusion or eustachian tube dysfunction. However, Weber's test focuses on lateralization of sound and does not require tympanogram readings.

Choice C rationale:

Placing a vibrating tuning fork on the top of the child's head is the correct action for performing Weber's test. By doing so, the nurse can assess whether the sound is perceived equally in both ears or if it is lateralized to one ear. If the sound is lateralized, it can provide valuable information about the type of hearing loss the child may have, whether it's conductive or sensorineural.

Choice D rationale:

Holding a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears is not the correct technique for Weber's test. Placing the tuning fork directly on the patient's forehead is essential for accurate assessment. Holding it close to the ears can lead to misinterpretation of the test results.


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Related Questions

Correct Answer is B

Explanation

Jaundice.

Rationale:

  • A. Weight loss is not a common or serious adverse effect of valproic acid. Valproic acid can cause weight gain, not weight loss.
  • B. Jaundice is a sign of liver damage, which is a serious and potentially fatal adverse effect of valproic acid. Valproic acid can impair fatty acid metabolism and mitochondrial function, leading to hepatotoxicity and steatosis. The nurse should monitor the client's liver function tests and report any signs of jaundice, such as yellowing of the skin or eyes, dark urine, or clay-colored stools .
  • C. Bradycardia is not a common or serious adverse effect of valproic acid. Valproic acid can cause cardiac arrhythmias, but they are usually tachycardic, not bradycardic.
  • D. Polyuria is not a common or serious adverse effect of valproic acid. Valproic acid can cause hypernatremia and hypocalcemia, which can affect urine output, but polyuria is not a specific symptom of these electrolyte imbalances.

Correct Answer is C

Explanation

"How does this make you feel?"

  • A. "I'm sure your family does not want you to die." is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's own assumptions. This choice is incorrect.
  • B. Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, which can increase the client's defensiveness and resistance. This choice is incorrect.
  • C. "How does this make you feel?" is a therapeutic response, as it encourages the client to express and explore their emotions, which can help to build rapport and trust with the nurse. This choice is correct.
  • D. "You should talk to your family about your feelings." is not a therapeutic response, as it implies that the client is responsible for resolving their own problems and that their family is willing and able to listen and support them, which may not be true. This choice is incorrect.

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