A nurse is collecting data from a 10-month-old infant during a well-child visit. Which of the following findings should the nurse identify as a manifestation of torticollis?
Neck is in a flexed position
Asymmetry of gluteal folds
Feet turn inward
Frenulum connected to the tip of the tongue
The Correct Answer is A
A. Neck is in a flexed position is correct. Torticollis (or wry neck) is a condition where the head is tilted to one side due to abnormal positioning of the neck muscles. The infant may exhibit a flexed or tilted neck, and there may be muscle tightness on one side of the neck.
B. Asymmetry of gluteal folds is incorrect. This finding is associated with hip dysplasia, not torticollis. Asymmetry of the folds could indicate a dislocated hip or other musculoskeletal issues.
C. Feet turn inward is incorrect. This finding suggests clubfoot rather than torticollis, a condition where the feet are turned inward and may require correctional intervention.
D. Frenulum connected to the tip of the tongue is incorrect. This describes a condition known as tongue-tie (ankyloglossia., which affects the tongue's movement and is unrelated to torticollis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Encouraging the client to write about her feelings in a journal each day.: While journaling can be therapeutic, it may not be the best immediate intervention. The client may first need support and validation of her feelings before engaging in such an activity.
B. Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds.: This is important for maintaining therapeutic communication, but it does not address the emotional distress the client is currently experiencing.
C. Identifying the client's perception of the changes in her physical appearance.: The client is likely struggling with body image changes following a bilateral mastectomy. The priority should be to assess the client’s emotional response to her altered appearance and to offer emotional support. This provides the foundation for helping the client process her feelings.
D. Providing the client with information on community resources that will strengthen her coping skills.: While community resources can be helpful later on, the immediate priority is understanding the client’s emotional response to her surgery. Once the nurse has established the client's emotional needs, then providing resources may be more appropriate.
Correct Answer is A
Explanation
A. Pain in the right upper abdomen is correct. Acute cholecystitis is the inflammation of the gallbladder, typically caused by gallstones blocking bile flow. This condition leads to severe right upper quadrant (RUQ) pain, often triggered by fatty meals and sometimes accompanied by nausea, vomiting, and fever.
B. Discomfort with urination is incorrect. Urinary discomfort is not associated with cholecystitis. This symptom is more indicative of urinary tract infections (UTIs) or kidney stones.
C. Pain radiating to the jaw is incorrect. Jaw pain is more characteristic of cardiac conditions, such as myocardial infarction (MI), rather than gallbladder inflammation.
D. Increased abdominal discomfort prior to meals is incorrect. Clients with cholecystitis typically experience more pain after meals, especially fatty foods, due to gallbladder contractions attempting to release bile.
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