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?
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.
Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
- A: Correct. Firmly massaging the uterine fundus helps to contract the uterus and reduce bleeding.
- B: Correct. Providing emotional support helps to calm the client and reduce anxiety, which can worsen bleeding.
- C: Correct. Administering oxygen helps to improve tissue perfusion and oxygenation, which can be compromised by blood loss. Weighing the perineal pads helps to quantify the amount of blood loss and monitor for hemorrhage.
- D: Correct. Inserting an indwelling urinary catheter helps to empty the bladder and allow the uterus to descend and contract more effectively. Administering methylergonovine helps to stimulate uterine contractions and control bleeding.
- E: Incorrect. Administering terbutaline is contraindicated in this situation, as it relaxes the uterine smooth muscle and increases bleeding.
Correct Answer is A
Explanation
- A. The nurse should discourage raw fruits due to risk of infection.
- B. There is no standard recommendation against exposure to young children.
- C. Incorrect. The nurse should measure the client's temperature at least every 4 hr, or more frequently if indicated because fever is a sign of infection in a client who has neutropenia and requires prompt intervention.
- D. Incorrect. The nurse should use disposable gloves from a box inside the client's room, not outside, to prevent cross-contamination and protect the client from exposure to pathogens.
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