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.

Answer and Explanation

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.

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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.

A. Consider this finding as normal, and proceed with the examination. B. Describe this dullness as indicative of an enlarged liver, and refer him to a physician. C. Document the presence of hepatomegaly. D. Ask additional health history questions regarding his alcohol intake.

Correct Answer is B

Explanation

A. Normal finding: This is not a normal finding. Dullness in this area could indicate an enlarged liver (hepatomegaly), which requires further evaluation.

B. Enlarged liver: Dullness above the right costal margin, especially around 11 cm, is often associated with hepatomegaly. The nurse should refer the patient to a physician for further investigation.

C. Hepatomegaly: While the finding could suggest hepatomegaly, the diagnosis should be confirmed by a physician. The nurse should refer the patient for further evaluation.

D. Alcohol intake: While it is relevant to ask about alcohol intake in the context of liver health, the immediate action is to refer the patient for further examination by a physician.

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In performing a voice test to assess hearing, which of these actions would the nurse perform?

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Naxlex Comprehensive Predictor Exams

During an abdominal assessment, the nurse tests for a fluid wave. What condition would produce a positive fluid wave test?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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