The nurse is assessing a client's hearing using the Rinne test. When providing instruction to elicit client feedback, which instruction is essential?
A) Raise your hand when you hear the vibration.
B) Raise your hand when you no longer hear sound.
C) Raise your hand when the vibration exceeds the sound.
D) Raise your hand when the sound exceeds the vibration.
B
Feedback:
It is essential to provide clear directions on when the client is to notify the nurse of client response. The information gleaned from the response is what the nurse uses to interpret the test. The correct time to induce feedback is when the vibration is held.
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