A school nurse is using 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.

Place a vibrating tuning fork on the top of the child's head.

Whisper a statement to the child from 0.6 m (2 feet) away.

Apply a pair of headphones securely over the child's ears

Answer and Explanation

The Correct Answer is B

A. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears – This describes the Rinne test, not the Weber test.

B. Place a vibrating tuning fork on the top of the child's head – Correct. The Weber test assesses hearing loss by placing a tuning fork on the midline of the skull to determine if sound is heard equally in both ears.

C. Whisper a statement to the child from 0.6 m (2 feet) away – This describes the whisper test, not the Weber test.

D. Apply a pair of headphones securely over the child's ears – Not part of the Weber test; this is used for audiometry testing.

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Correct Answer is C

Explanation

A. Placing the client in Trendelenburg position is incorrect because this position does not reduce tension on the abdominal wound and may increase intra-abdominal pressure.

B. Reinserting the protruding intestinal tissue is incorrect because this can introduce infection and cause further damage.

C. This is the correct answer. The priority action is to cover the wound with a sterile, saline-moistened dressing to prevent tissue drying and reduce infection risk.

D. Monitoring vital signs is important, but the priority is to protect the exposed abdominal contents.

A. "You might notice some changes in your voice after the procedure." B. "You might feel a bit confused for a few hours after the procedure." C. "You'll wake up about 30 minutes after the procedure." D. "You can expect to feel some pulsations in your neck during the procedure."

Correct Answer is B

Explanation

A. ECT does not typically affect a client’s voice.

B. This is the correct answer. A common side effect of ECT is short-term confusion and memory impairment, which can last for minutes to a few hours after the procedure.

C. Most clients wake up within a few minutes, not 30 minutes.

D. Clients do not typically feel pulsations in the neck during the procedure since they are under anesthesia and muscle relaxants are used.

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A school nurse is using Weber's test to check a child's hearing acuity. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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