A nurse enters a client's room and finds the client on the ﬂoor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take?

Insert a padded tongue blade into the client's mouth.

Keep the client in a supine position.

Gently restrain the client's extremities.

Place a pillow under the client's head.

Answer and Explanation

The Correct Answer is D

The nurse should place a pillow under the client's head if the client is on the ﬂoor in the clonic phase of a tonic-clonic seizure. This can help protect the client's head from injury during the seizure.

Inserting a padded tongue blade into the client's mouth, keeping the client in a supine position, and gently restraining the client's extremities are not appropriate interventions for the nurse to take in this situation. Inserting a padded tongue blade into the client's mouth can cause injury to the teeth and gums. Keeping the client in a supine position can increase the risk of aspiration. Gently restraining the client's extremities can cause injury and is not recommended during a seizure.

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Correct Answer is A

Explanation

The nurse should report sudden sleepiness to the provider immediately if the client has a traumatic head injury. Sudden sleepiness can indicate an increase in intracranial pressure, which can be a life-threatening complication of a head injury.

Headache, diplopia, and slight ataxia are also important findings that the nurse should report to the provider. However, these findings are not as urgent as sudden sleepiness. Headache can be a common symptom following a head injury. Diplopia is double vision and can indicate cranial nerve damage. Slight ataxia is unsteadiness or lack of coordination and can indicate neurological damage.

A. Pivot B. Hinge C. Ball and socket D. Gliding

Correct Answer is B

Explanation

The knee is a hinge type of joint. When describing range-of-motion exercises, the nurse should explain that the knee is a hinge joint. A hinge joint is a type of synovial joint that mainly allows for ﬂexion and extension (and a small degree of medial and lateral rotation)¹. The knee joint is formed by articulations between the patella, femur, and tibia.

a. The knee is not a pivot joint.
c. The knee is not a ball and socket joint.
d. The knee is not a gliding joint.

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A nurse enters a client's room and finds the client on the ﬂoor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has a traumatic head injury. Which of the following findings should the nurse report to the provider immediately?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has a knee injury. When describing range-of-motion exercises, the nurse should explain that the knee is which of the following types of joints?

Correct Answer is B

Explanation

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