A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?
Deliver a series of high-pitched sounds at random intervals.
Place an activated tuning fork in the middle of the client's forehead.
Hold an activated tuning fork against the client's mastoid process.
Whisper a series of words softly into one ear.
The Correct Answer is B
A. Delivering a series of high-pitched sounds at random intervals is not related to the Weber's test.
B. Weber's test is performed by striking the tuning fork and placing it against the middle of the forehead. Ask the patient if the tone is equal in both ears. Diminution in the affected ear indicates sensorineural hearing loss.
C. Placing an activated tuning fork on the client's mastoid process is not part of the Weber's test.
D. Whispering a series of words softly into one ear is unrelated to the Weber's test; it's a test for assessing auditory acuity.
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Related Questions
Correct Answer is C
Explanation
A. Dismissing concerns by suggesting that they won't need to worry with physical therapy is not therapeutic. It invalidates the client's feelings.
B. Discouraging the client from worrying may seem dismissive of their emotions and concerns.
C. Acknowledging and reflecting the client's concern about the future demonstrates empathy and encourages further discussion.
D. Asking why the client is concerned might make them feel defensive and does not validate their emotions.
Correct Answer is B
Explanation
Rationale for A: Side-lying with the right side of the chest elevated does not provide the necessary gravitational effect to drain the left lower lobe. The Trendelenburg position is more effective for lower lobe drainage.
Rationale for B: Right lateral in Trendelenburg position is the appropriate position for postural drainage of the left lower lobe. The combination of gravity and positioning helps drain secretions from the lower lobe effectively.
Rationale for C: Prone with pillows under the lower extremities does not facilitate proper drainage of the left lower lobe. This position might be more useful for posterior lobe drainage, not the lower lobes.
Rationale for D: Supine in low-Fowler's position is not ideal for draining secretions from the lower lobes of the lungs. Postural drainage requires specific positions that use gravity to promote secretion clearance from the affected lobe.
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