A nurse is receiving a report on a group of clients. For which of the following clients should the nurse implement airborne precautions?

A. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears: This describes air conduction testing used in the Rinne test, not the Weber test. In Weber’s test, the goal is to assess lateralization of sound through bone conduction, so placing the fork near the ear canal does not provide the intended diagnostic information.

B. Place a vibrating tuning fork on the top of the child's head: Weber’s test evaluates bone conduction by placing a vibrating tuning fork at the midline of the skull, on the forehead or vertex. The child is asked where the sound is heard best. In normal hearing, sound is heard equally in both ears, while lateralization suggests conductive or sensorineural hearing loss.

C. Measure the amount of time the child can hear the sound: Measuring duration of sound perception is part of the Rinne test, which compares air conduction to bone conduction. Weber’s test focuses on sound localization rather than duration, so this action does not align with the purpose of the test.

D. Obtain a tympanogram reading prior to initiating the test: Tympanometry is a separate diagnostic procedure used to assess middle ear function and eardrum mobility. It is not a prerequisite for performing a Weber test, which is a simple bedside screening using a tuning fork.

Question: 54 of 85

A. Edema: Edema is typically associated with fluid overload or conditions that cause fluid retention, such as heart failure or kidney disease. In dehydration, the body loses fluid volume, making edema an unlikely finding.

B. Hypotension: Hypotension is a common clinical manifestation of dehydration due to decreased intravascular volume. Loss of fluid reduces cardiac output and systemic perfusion, leading to low blood pressure, which can be exacerbated by prolonged diarrhea.

C. Crackles: Crackles on auscultation are associated with pulmonary fluid accumulation, such as in heart failure or pulmonary edema. Dehydrated clients generally have reduced extracellular fluid volume, making crackles an unexpected finding.

D. Bradycardia: Dehydration typically triggers a compensatory increase in heart rate (tachycardia) to maintain perfusion despite decreased blood volume. Bradycardia is not expected and may indicate other cardiac abnormalities rather than fluid loss.