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A nurse is caring for a client who states during a counseling session, "I am sliding off a cliff." Which of the following statements should the nurse make?

"I don't think that is really what is happening to you."

"Don't worry. Everything will be okay."

"How are things going at your job?"

"You must be feeling very frightened right now."

Answer and Explanation

The Correct Answer is D

A. This statement dismisses the client's feelings.

B. Offering false reassurance is not therapeutic.

C. Changing the subject does not address the client's distress.

D. This is the correct answer. Acknowledging the client's feelings is a therapeutic response that encourages further discussion.

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Correct Answer is A

Explanation

A. Suction the client's airway – This is the correct answer. A high-pressure alarm on a ventilator usually indicates an obstruction, such as mucus plugging or secretions in the airway. Suctioning helps clear the obstruction.

B. Look for a leak in the tube's cuff – A leak would trigger a low-pressure alarm, not a high-pressure alarm.

C. Tighten the tubing connections – Loose connections generally cause low-pressure alarms rather than high-pressure alarms.

D. Request insertion of a tracheostomy tube – This may be necessary for long-term ventilation, but it is not the immediate intervention for a high-pressure alarm.

A. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears. B. Place a vibrating tuning fork on the top of the child's head. C. Whisper a statement to the child from 0.6 m (2 feet) away. D. Apply a pair of headphones securely over the child's ears

Correct Answer is B

Explanation

A. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears – This describes the Rinne test, not the Weber test.

B. Place a vibrating tuning fork on the top of the child's head – Correct. The Weber test assesses hearing loss by placing a tuning fork on the midline of the skull to determine if sound is heard equally in both ears.

C. Whisper a statement to the child from 0.6 m (2 feet) away – This describes the whisper test, not the Weber test.

D. Apply a pair of headphones securely over the child's ears – Not part of the Weber test; this is used for audiometry testing.

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A nurse is caring for a client who states during a counseling session, "I am sliding off a cliff." Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A school nurse is using Weber's test to check a child's hearing acuity. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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