A school nurse is using the Weber's test to check a child's hearing acuity. Which of the following actions should the nurse take?
Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears.
Measure the amount of time the child can hear the sound.
Obtain a tympanogram reading prior to initiating the test.
Place a vibrating tuning fork on the top of the child's head.
The Correct Answer is D
A. Holding a vibrating tuning fork 1 to 2 cm from the child's ears is not a part of the Weber's test procedure. The Weber's test involves assessing lateralization of sound in cases of unilateral hearing loss. Placing the tuning fork close to the ears may interfere with the accuracy of the test.
B. Measuring the amount of time the child can hear the sound is not relevant to the Weber's test. This action does not assess lateralization of sound but rather evaluates the duration of hearing.
C. Obtaining a tympanogram reading is not necessary before initiating the Weber's test. Tympanometry is a separate test used to assess the function of the middle ear, particularly the movement of the eardrum and the conduction bones.
D. Placing a vibrating tuning fork on the top of the child's head is the correct action for performing the Weber's test. During this test, the nurse activates a tuning fork and places it on the midline of the child's head or forehead. The child is asked if they hear the sound equally in both ears or if it is louder in one ear than the other. This helps determine if there is asymmetrical hearing loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
A. Diaphoresis: Diaphoresis, or excessive sweating, is a common side effect of clozapine and may not necessarily indicate a need for immediate intervention. However, it should be documented and monitored for any changes.
B. Fever: Fever can be a sign of infection, which is a serious concern in clients taking clozapine due to the risk of agranulocytosis, a potentially life-threatening side effect characterized by a severe decrease in white blood cell count. Any signs of infection, including fever, should be reported promptly to the provider for further evaluation and management.
C. Polyuria: Polyuria, or excessive urination, is not typically associated with clozapine use and may be indicative of other underlying issues such as diabetes mellitus or diabetes insipidus. While it should be assessed and managed appropriately, it is not specifically related to clozapine administration and may not require immediate reporting to the provider.
D. Diarrhea: Diarrhea is a common gastrointestinal side effect of clozapine and may occur due to its effects on the gastrointestinal system. While persistent or severe diarrhea should be monitored and managed, it is not typically considered a serious adverse reaction that requires immediate reporting to the provider unless it is accompanied by other concerning symptoms.
Correct Answer is B
Explanation
A. Hepatitis A - Hepatitis A vaccine is typically administered in two doses, with the first dose given at 12-23 months of age. It is not routinely given at 2 months of age.
B. Rotavirus - Rotavirus vaccine is recommended for administration at 2 months of age, with subsequent doses given at 4 and 6 months. It helps protect against rotavirus infection, a common cause of severe diarrhea in infants and young children.
C. Influenza - Influenza vaccine is usually not administered until 6 months of age. Infants younger than 6 months are considered too young to receive the influenza vaccine.
D. Varicella - Varicella (chickenpox) vaccine is typically given in two doses, with the first dose recommended at 12-15 months of age. It is not routinely administered at 2 months of age.
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