The nurse is assessing a patient's hearing using the Weber test. How is this test performed?

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Question 1 of 5

The nurse is assessing a patient's hearing using the Weber test. How is this test performed?

Correct Answer: B

Rationale: The correct answer is B because the Weber test is performed by striking a tuning fork and placing it on the patient's forehead. This causes vibrations that are conducted through the skull to both cochleas. In a normal hearing individual, the sound will be heard equally in both ears. If there is unilateral conductive hearing loss, the sound will be louder in the affected ear, and if there is unilateral sensorineural hearing loss, the sound will be louder in the unaffected ear. Choice A is incorrect because the Weber test does not involve whispering words for the patient to repeat. Choice C is incorrect because it describes the Rinne test, not the Weber test. Choice D is incorrect because it does not involve identifying different tones, but rather assessing for lateralization of sound.

Question 2 of 5

The nurse is assessing a patient's level of consciousness using the Glasgow Coma Scale. Which component is not included in this scale?

Correct Answer: D

Rationale: The correct answer is D: Pupil size. The Glasgow Coma Scale (GCS) assesses a patient's level of consciousness based on eye opening, motor response, and verbal response. Pupil size is not included in the GCS as it focuses on assessing the patient's neurological status and responsiveness to stimuli. Pupil size is typically assessed separately as part of a neurologic examination but is not a component of the GCS. Therefore, D is the correct answer. A, B, and C are incorrect because they are the three components (eye opening, motor response, verbal response) included in the Glasgow Coma Scale.

Question 3 of 5

The nurse is assessing a patient's respiratory system and notes the presence of stridor. What does this finding most likely indicate?

Correct Answer: B

Rationale: The presence of stridor indicates upper airway obstruction. Stridor is a high-pitched, inspiratory sound that occurs when there is partial obstruction in the upper airway, typically in the larynx or trachea. This sound is produced as air passes through a narrowed or partially blocked airway during inhalation. Lower airway obstruction (Choice A) typically presents with wheezing, not stridor. Pleural effusion (Choice C) is the accumulation of fluid in the pleural space, which would not cause stridor. Pulmonary edema (Choice D) is the accumulation of fluid in the lungs, leading to crackles on auscultation, not stridor.

Question 4 of 5

Which finding during a neurological assessment suggests damage to cranial nerve VIII (vestibulocochlear nerve)?

Correct Answer: B

Rationale: The correct answer is B: Loss of balance and hearing. Damage to cranial nerve VIII (vestibulocochlear nerve) affects balance and hearing as it is responsible for transmitting sensory information related to equilibrium and sound perception. Loss of balance indicates dysfunction in the vestibular component of the nerve, while hearing loss is related to the cochlear component. Difficulty swallowing (choice A) is associated with cranial nerves IX and X. Impaired eye movement (choice C) is linked to cranial nerves III, IV, and VI. Weakness in shoulder shrugging (choice D) is typically attributed to cranial nerve XI.

Question 5 of 5

Which cranial nerve is being tested when the nurse asks the patient to stick out their tongue?

Correct Answer: D

Rationale: The correct answer is D, Cranial nerve XII (hypoglossal nerve). This nerve innervates the muscles responsible for tongue movement. When the nurse asks the patient to stick out their tongue, they are testing the function of the hypoglossal nerve. The hypoglossal nerve controls the intrinsic and extrinsic muscles of the tongue, allowing for movements such as protrusion, retraction, and side-to-side movements. Choices A, B, and C are incorrect because they do not directly relate to tongue movement. Cranial nerve IX (glossopharyngeal nerve) is involved in taste perception and swallowing, cranial nerve X (vagus nerve) is involved in various autonomic functions and cranial nerve XI (spinal accessory nerve) controls certain neck muscles.

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