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?

Pivot

Hinge

Ball and socket

Gliding

Answer and Explanation

The Correct Answer is B

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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Correct Answer is D

Explanation

The nurse should immediately report small drops of clear ﬂuid in the left ear to the charge nurse. This finding could indicate a cerebrospinal ﬂuid (CSF) leak, which can occur as a result of a head injury. A CSF leak can be a serious medical condition that requires immediate attention.

An edematous bruise on the forehead, client disorientation to place, and a heart rate of 110/min and regular are also important findings that the nurse should report to the charge nurse. However, these findings are not as urgent as the presence of small drops of clear ﬂuid in the left ear.

A. Administer opioids. B. Apply restraints. C. Reduce stimuli. D. Blacken the room.

Correct Answer is C

Explanation

An appropriate nursing action for a client who is restless following a traumatic brain injury with increased intracranial pressure is to reduce stimuli. This can help calm the client and prevent further increases in intracranial pressure. The nurse can reduce stimuli by minimizing noise and light in the client's environment and limiting the number of visitors.

Administering opioids, applying restraints, and blackening the room are not appropriate nursing actions for this situation. Administering opioids can cause respiratory depression and is not recommended for clients with increased intracranial pressure. Applying restraints can increase agitation and is not recommended for clients who are restless. Blackening the room can disorient the client and is not recommended.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?

Correct Answer is D

Explanation

A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action?

Correct Answer is C

Explanation

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