A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first?

Test the drainage for glucose.

Take the client's temperature.

Notify the charge nurse.

Place a dressing under the client's nose.

Answer and Explanation

The Correct Answer is A

The first action the nurse should take is to test the drainage for glucose. Clear drainage from the nose following a basal skull fracture could indicate a cerebrospinal ﬂuid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help determine if it is CSF.

b. Taking the client's temperature is not the first action the nurse should take.
c. Notifying the charge nurse is important but not the first action the nurse should take.
d. Placing a dressing under the client's nose is not the first action the nurse should take.

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Correct Answer is D

Explanation

a. Decorticate posturing is marked by the flexion of the arms, with the hands clenched into fists and the legs extended and internally rotated.
b. External rotation of the lower extremities is not a characteristic of decorticate posturing. In decorticate posture, legs are held out straight.

c.Pronation of the hands is characteristic of decerebrate posturing, where the arms are extended and pronated.

d. In decorticate posturing, the lower extremities typically exhibit plantar flexion. Additionally, the upper extremities show flexion of the arms, wrists, and fingers with adduction of the arms.

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 is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?

Correct Answer is D

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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