A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?
Whisper a series of words softly into one ear.
Place an activated tuning fork in the middle of the client's forehead.
Deliver a series of high-pitched sounds at random intervals.
Hold an activated tuning fork against the client's mastoid process.
The Correct Answer is B
A. Whisper a series of words softly into one ear.
Explanation: Whispering words into one ear is not part of Weber's test. This action is more relevant to the assessment of hearing acuity and not the lateralization of sound. Weber's test focuses on the perception of sound in relation to both ears, not the ability to hear whispered words.
B. Place an activated tuning fork in the middle of the client's forehead.
Explanation: In Weber's test, a tuning fork is placed in the middle of the client's forehead. The test is designed to assess whether sound lateralizes (moves) to one ear or is heard equally in both ears. If the client perceives the sound more in one ear than the other, it may indicate a hearing imbalance or issue.
C. Deliver a series of high-pitched sounds at random intervals.
Explanation: Delivering high-pitched sounds at random intervals is not part of Weber's test. Weber's test involves a single action – placing an activated tuning fork in the middle of the client's forehead. The purpose is to determine if the client perceives the sound equally in both ears or if there is lateralization. Random intervals and high-pitched sounds are not specified components of this test.
D. Hold an activated tuning fork against the client's mastoid process.
Explanation: While holding a tuning fork against the mastoid process is part of another hearing test called the Rinne test, it is not the appropriate action for the Weber's test. The Rinne test compares air conduction (using the tuning fork near the ear) to bone conduction (using the tuning fork against the mastoid process) to evaluate hearing in each ear. In Weber's test, we are specifically interested in lateralization of sound, not comparing air and bone conduction.
![Solved] In Weber's test, lateralization of sound to diseased ear](https://lh7-us.googleusercontent.com/ONts3eztTfKhEj3KDwZAZTfLmrkDcfa0p_jNkiWuQWdEYwepzjQliO-_0EFssyppqCY2GkKManp0hjINsm4nXW-dI2qUDduLrVP_SuAvQrpfFMnlsPCp3rc_9NNf7y9W0NNf4dmDYe3WV2jPLyBsEw)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. An assistive personnel prevents a client from leaving the facility:
This situation may raise ethical concerns related to patient autonomy and freedom of movement. However, it is not a clear example of negligence. Negligence is more directly related to the provision of care and the failure to meet the standard of care.
B. An assistive personnel discusses client care in the facility cafeteria with visitors present:
This situation involves a breach of confidentiality and may violate the Health Insurance Portability and Accountability Act (HIPAA). However, it is not an example of negligence. Negligence typically involves a failure to provide appropriate care rather than a breach of privacy.
C. A nurse administers a medication without first identifying the client:
This is an example of negligence. Negligence refers to the failure to provide the standard of care that a reasonably prudent person would have provided under similar circumstances. In this case, administering medication without first identifying the client is a breach of the standard of care, and it can lead to serious consequences, including harm to the patient.
D. A nurse begins a blood transfusion without obtaining consent from a client:
This is an example of a legal issue related to lack of informed consent. While it raises ethical and legal concerns, it may not necessarily be considered negligence, which is more related to a failure in providing care up to the standard. However, it is still a serious violation of ethical and legal principles.
Correct Answer is A
Explanation
A. Administer the client's medications one at a time:
This is the correct action. Administering medications one at a time allows the nurse to monitor the client's ability to swallow each medication safely. It minimizes the risk of aspiration and ensures that each medication is swallowed effectively.
B. Encourage the client to use a straw to take the medications:
Using a straw may not be recommended for clients with dysphagia, as it can alter the normal swallowing process and increase the risk of aspiration. The focus should be on safe administration of medications without compromising the client's ability to swallow.
C. Give the client's medications between meals:
The timing of medication administration is important, but the priority is the safe administration of medications, especially for clients with dysphagia. Administering medications between meals may not directly address the safety concerns related to swallowing.
D. Assist the client into semi-Fowler's position:
While positioning is important, especially for clients with dysphagia, the administration of medications one at a time (Option A) takes precedence in ensuring the safety of the client's swallowing. Semi-Fowler's position may be beneficial, but it is not the primary action related to medication administration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today