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    ATI health assessment proctored exam

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

    Explanation & Rationale

    A. Whisper a set of random numbers and letters, and then ask the patient to repeat them: The whispered voice test is a simple and reliable screening method for hearing loss. The nurse stands about 2 feet behind the patient, whispers a series of random numbers or letters, and asks the patient to repeat them. This helps assess high-frequency hearing loss. B. Shield the lips so that the sound is muffled: While the test is performed without the patient seeing the nurse’s lips to prevent lip reading, deliberately muffling the sound is unnecessary and may alter the accuracy of the assessment. C. Stand approximately 6 feet away to ensure that the patient can really hear at this distance: The whispered voice test is conducted at a standard distance of about 2 feet, not 6 feet. Increasing the distance may make the test unreliable. D. Ask the patient to place his or her finger in their ears to occlude outside noise: The test should be performed in a quiet environment, but instructing the patient to occlude their ears is unnecessary. Instead, the nurse tests one ear at a time by covering the opposite ear.

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