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?
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.
Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears.
The Correct Answer is C
Choice A rationale:
Measuring the amount of time the child can hear the sound is not the correct action when performing Weber's test. Weber's test is used to assess hearing acuity and lateralization. In this test, a vibrating tuning fork is placed in the middle of the patient's forehead, and the patient is asked if the sound is heard equally in both ears or if it is louder in one ear. This helps identify whether there is a conductive or sensorineural hearing loss. The duration of hearing the sound is not relevant to this test.
Choice B rationale:
Obtaining a tympanogram reading is not necessary before initiating Weber's test. Tympanometry assesses the movement of the eardrum in response to changes in air pressure and can help diagnose conditions like middle ear effusion or eustachian tube dysfunction. However, Weber's test focuses on lateralization of sound and does not require tympanogram readings.
Choice C rationale:
Placing a vibrating tuning fork on the top of the child's head is the correct action for performing Weber's test. By doing so, the nurse can assess whether the sound is perceived equally in both ears or if it is lateralized to one ear. If the sound is lateralized, it can provide valuable information about the type of hearing loss the child may have, whether it's conductive or sensorineural.
Choice D rationale:
Holding a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears is not the correct technique for Weber's test. Placing the tuning fork directly on the patient's forehead is essential for accurate assessment. Holding it close to the ears can lead to misinterpretation of the test results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
- A. Oliguria. This is incorrect because oliguria, or decreased urine output, is a sign of fluid volume deficit, not fluid volume overload.
- B. Bradycardia. This is incorrect because bradycardia, or slow heart rate, is not a typical sign of fluid volume overload, unless the client has a cardiac condition that affects the heart's response to fluid overload.
- C. Dyspnea. This is correct because dyspnea, or difficulty breathing, is a common sign of fluid volume overload, as excess fluid accumulates in the lungs and impairs gas exchange.
- D. Poor skin turgor. This is incorrect because poor skin turgor, or decreased elasticity of the skin, is a sign of dehydration, not fluid volume overload.
Correct Answer is B
Explanation
A. "Limit each of the client's visitors to 2 hr per day."
This is incorrect. While visitors should have their exposure limited, the recommended duration is typically much shorter (around 30 minutes to 1 hour), not 2 hours. This is to reduce radiation exposure.
B. "Instruct visitors to stay 1 m (3.3 feet) away from the client."
This is correct. For clients undergoing brachytherapy with a low-dose radiation implant, visitors should maintain a safe distance, usually at least 6 feet (1.8 meters), but some guidelines may state a minimum of 3.3 feet (1 meter) for safety, depending on the specific radiation dose and facility protocols.
C. "Attach a dosimeter to the client's gown."
This is incorrect. Dosimeters are generally worn by healthcare providers, not the patient. The primary purpose is to measure the radiation exposure of healthcare workers, not the patient.
D. "Strain the client's urine."
This is incorrect. Straining urine is not necessary for a patient undergoing brachytherapy. However, it may be important to monitor the urine for signs of radiation leakage, but straining is not a routine part of care.
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