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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. "Clean the client's skin with soap and hot water" is incorrect. Soap and hot water can be harsh on the skin and can cause irritation, especially in clients who are at risk for skin breakdown. The nurse should use lukewarm water and a gentle cleanser to clean the skin.

B. "Limit the client's fluid intake" is incorrect. Limiting fluid intake is not a recommended approach for preventing skin breakdown. Proper hydration helps maintain skin elasticity and prevent dryness.

C. "Use a moisture barrier on the client's skin" is correct. A moisture barrier is crucial for protecting the skin from prolonged exposure to moisture from incontinence, which can lead to skin breakdown. The barrier helps prevent irritation and allows the skin to stay intact.

D. "Massage the area around the client's coccyx" is incorrect. Massaging over bony prominences, such as the coccyx, is not recommended, as it can damage tissue and increase the risk of pressure ulcers. The nurse should avoid massaging these areas.

A. "Once my health care proxy is in place, I relinquish my right to make my own decisions." B. "My health care proxy designee is not able to sign a consent form on my behalf." C. "If I have a health care proxy, then I do not need to have a living will." D. "I do not need to name a relative as my designee in my health care proxy."

Correct Answer is D

Explanation

A. "Once my health care proxy is in place, I relinquish my right to make my own decisions" is incorrect. A health care proxy only comes into effect when the individual becomes incapacitated and unable to make decisions. Until then, the client retains the right to make their own decisions.

B. "My health care proxy designee is not able to sign a consent form on my behalf" is incorrect. The health care proxy designee is authorized to make decisions about medical treatment, which includes signing consent forms on the client’s behalf if the client is unable to do so.

C. "If I have a health care proxy, then I do not need to have a living will" is incorrect. A living will and a health care proxy are separate documents. A living will specify a person’s wishes regarding medical treatments in case they are unable to communicate, while a health care proxy designates someone to make decisions on their behalf. Both can be used together.

D. "I do not need to name a relative as my designee in my health care proxy" is correct. The designee does not have to be a relative. The client can choose anyone they trust to make healthcare decisions on their behalf when they are unable to do so.

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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?

Nursing Test Bank

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