In performing a voice test to assess hearing, which of these actions would the nurse perform?
Shield the lips so that the sound is muffled.
Whisper a set of random numbers and letters, and then ask the patient to repeat them.
Ask the patient to place his finger in his ear to occlude outside noise.
Stand approximately 4 feet away to ensure that the patient can really hear at this distance.
The Correct Answer is B
A. Shield the lips: Shielding the lips ensures the patient is not lip-reading but should not muffle the sound.
B. Whisper random numbers and letters: The whisper test involves standing behind the patient, whispering a series of numbers and letters, and asking the patient to repeat them.
C. Occlude outside noise: Asking the patient to occlude one ear may alter test results.
D. Stand approximately 4 feet away: The whisper test is typically performed from 1-2 feet behind the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"D"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"}}
Explanation
Assessment Technique |
1 |
2 |
3 |
4 |
Percussion |
✅ |
|||
Inspection |
✅ |
|||
Palpation |
✅ |
|||
Auscultation |
✅ |
Rationale:
Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
Correct Answer is D
Explanation
A. Constipation: This involves hardened stool in the colon, causing localized distention but no free fluid.
B. Splenomegaly: Enlargement of the spleen causes a palpable mass in the left upper quadrant but no free fluid.
C. Distended bladder: This causes suprapubic distension but does not produce a fluid wave.
D. Ascites: A positive fluid wave test indicates free fluid in the abdominal cavity, a hallmark sign of ascites. The test is performed by tapping one side of the abdomen and observing for a wave-like transmission of fluid to the opposite side.
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