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
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 monitor the client for lethargy as a manifestation of increased intracranial pressure. Increased intracranial pressure (ICP) is a rise in pressure around the brain that can occur due to various reasons such as brain injury, bleeding into the brain, swelling in the brain, or an increase in cerebrospinal fluid. Lethargy (feeling less alert than usual) is a common symptom of increased ICP.
a. Nuchal rigidity is not a common symptom of increased ICP.
b. Batle's sign is not a common symptom of increased ICP.
c. Polyuria is not a common symptom of increased ICP.
Correct Answer is B
Explanation
Halo-vest traction immobilizes a patient’s head and neck after traumatic injury to the cervical vertebrae as well as helping to prevent further injury to the spinal cord². Elevating the head of the bed can help improve the patient's comfort and reduce the risk of complications such as aspiration.
a. Placing the client in a supine position is not necessarily required for a patient in halo traction. The position of the patient should be determined by their individual needs and comfort.
c. Applying a pelvic girdle is not necessary for a patient in halo traction. Halo-vest traction consists of a metal ring that fits over the patient’s head and metal bars that connect the ring to a plastic vest that distributes the weight of the entire apparatus around the chest².
d. Elevating the foot of the bed is not necessary for a patient in halo traction. The position of the bed
should be determined by the patient's individual needs and comfort.
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