A nurse is testing a client for conduction deafness by performing the Weber's test. Which of the following actions should the nurse take when performing this test?
Place the base of a vibrating tuning fork on the top of the client's head.
Count how many seconds a client can hear a tuning fork after it has been struck.
Place the base of a vibrating tuning fork on the client's mastoid process.
Move a vibrating tuning fork in front of the client's ear canals one after the other.
The Correct Answer is A
The correct answer is that the nurse should place the base of a vibrating tuning fork on the top of the client's head when performing Weber's test. Weber's test is a screening test for hearing that can detect unilateral (one-sided. conductive hearing loss (middle ear hearing loss) and unilateral sensorineural hearing loss (inner ear hearing loss)².
Options b, c and d are not correct actions for performing Weber's test. Counting how many seconds a client can hear a tuning fork after it has been struck, placing the base of a vibrating tuning fork on the client's mastoid process and moving a vibrating tuning fork in front of the client's ear canals one after the other are not part of Weber's test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The client's statement that they will place the suppository as far inside their vagina as they can reach indicates an understanding of the teaching. This ensures that the medication is delivered to the site of infection.
a. The client should continue to use the medication for the full course of treatment, even if their symptoms improve before the treatment is complete.
b. The client can lie on their back or side to insert the suppository; there is no specific requirement to lie on their left side.
c. Lubricant is not typically necessary for the insertion of a vaginal suppository.
Correct Answer is ["F"]
Explanation
f) Skin surrounding the stoma is reddened and appears irritated.
The information that requires intervention by the nurse is that the skin surrounding the stoma is reddened and appears irritated. This may indicate that the client is experiencing skin irritation or breakdown, which can lead to infection or other complications. The nurse should assess the skin and initiate appropriate interventions to prevent further skin damage.
Options a, b, c, d, e, and g do not necessarily require intervention by the nurse. A pink ileostomy stoma and moderate brown liquid stool drainage are normal findings. The client's refusal to look at the stoma or learn about stoma care may be concerning, but it is not an immediate priority for intervention. An intake of 2,200 mL over 24 hours and a urine output of 650 mL over 24 hours are within normal limits.
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