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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","C","E"]

Explanation

The correct answer is B, C, and E.

  • A. Weight is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition.
  • B. Neuro status is a correct choice because it reflects the client's level of consciousness, orientation, memory, and cognitive function. Any alteration in neuro status could indicate a serious problem such as infection, stroke, or medication toxicity.
  • C. Auditory hallucinations are a correct choice because they are a symptom of psychosis and could indicate a relapse or worsening of the client's mental illness. Auditory hallucinations could also impair the client's ability to cope, communicate, and function effectively.
  • D. Speech is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition. Speech could be affected by various factors such as mood, anxiety, or medication side effects.
  • E. Restlessness is a correct choice because it is a sign of agitation, anxiety, or discomfort. Restlessness could also indicate an underlying physical or psychological problem such as pain, infection, or psychosis.

Correct Answer is D

Explanation

- A. Instructing the client about the importance of regular medical appointments is important, but not the priority. The nurse should first ensure that the client knows how to manage their blood glucose levels and administer insulin at home.

- B. Encouraging the client to participate in daily exercise is beneficial, but not the priority. The nurse should first ensure that the client knows how to monitor their blood glucose levels and adjust their insulin dose accordingly.

- C. Explaining proper foot care techniques to the client is essential, but not the priority. The nurse should first ensure that the client knows how to prevent and treat hypoglycemia and hyperglycemia, which can have serious complications.

- D. Ensuring that the client understands the medication regimen is the priority. The nurse should teach the client about the types, actions, doses, and administration times of insulin, as well as how to store and dispose of it safely.

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