A nurse is performing Weber's test for a client who has hearing loss. Which of the following actions should the nurse take?

Place a vibrating tuning fork against the midline vertex of the client's head.

Have the client repeat a phrase spoken by the nurse while the nurse's mouth is hidden.

Whisper words for the client to identify.

Ask the client to occlude one ear with a finger.

Answer and Explanation

The Correct Answer is A

A. Place a vibrating tuning fork against the midline vertex of the client's head: The Weber test is performed by placing a vibrating tuning fork on the midline of the client's forehead or vertex of the head. This tests for lateralization of sound, helping to distinguish between conductive and sensorineural hearing loss based on which ear hears the sound louder.

B. Have the client repeat a phrase spoken by the nurse while the nurse's mouth is hidden: This action refers to the "speech discrimination test" rather than the Weber test. It is not part of the Weber test, which is specifically used to assess the lateralization of sound.

C. Whisper words for the client to identify: This refers to a different hearing test, called the "whisper test," used to assess hearing ability, not the Weber test. The Weber test specifically uses a tuning fork to assess how sound is heard by the client.

D. Ask the client to occlude one ear with a finger: While blocking one ear can be used in other tests (like Rinne's test), it is not necessary for the Weber test, which involves placing the tuning fork in the center of the head.

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Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A. Provide a mask for the client when they are outside their room: The client has a positive influenza test, it is important to prevent the spread of the virus to others by wearing a mask when outside their room to minimize the risk of transmission through respiratory droplets.

B. Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room. While hand sanitizer is appropriate for influenza, droplet precautions, the client also has Clostridium difficile, which requires contact precautions, specifically hand hygiene with soap and water. Alcohol-based hand sanitizers are not effective against C. diff spores.

C. Don a gown when entering the client's room: The client is positive for C. difficile, which requires contact precautions. Wearing a gown when entering the room is necessary to protect healthcare workers from coming into contact with potentially contaminated surfaces or materials.

D. When removing personal protective equipment, remove gloves first: When removing personal protective equipment gloves should be removed first to avoid contamination of other surfaces. This is the recommended sequence for safe removal of PPE in contact precautions.

E. Place the client in a room with positive air flow: A room with positive air flow is necessary for airborne precautions (e.g., for tuberculosis or varicella), but it is not required for C. difficile or influenza, which are both managed through contact and droplet precautions.

A. Persistent repositioning of objects B. No response to tactile stimuli C. Decreased attention span D. Presence of expressive aphasia

Correct Answer is C

Explanation

A. Persistent repositioning of objects: Repositioning objects frequently is more likely to be related to issues like anxiety or cognitive concerns rather than a hearing deficit. It does not typically indicate a hearing issue.

B. No response to tactile stimuli: No response to tactile stimuli suggests a possible sensory deficit related to touch or neurological concerns, but it does not indicate a hearing deficit. Hearing deficits affect auditory perception, not tactile sensations.

C. Decreased attention span: A decreased attention span can be a sign of hearing impairment, as individuals with hearing deficits may have difficulty following conversations or may become distracted due to not fully engaging with their environment.

D. Presence of expressive aphasia: Expressive aphasia is related to difficulty with speech production and language, typically following neurological events like strokes. It is not directly associated with hearing deficits but rather with language processing.

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A nurse is performing Weber's test for a client who has hearing loss. Which of the following actions should the nurse take?

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