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 B
Explanation
A. Exercising when insulin is at its peak action is incorrect. Exercising during peak insulin activity increases the risk of hypoglycemia. It is best to exercise when insulin levels are more stable, such as 1 to 2 hours after a meal.
B. Eating a piece of fruit before exercising is correct. A small carbohydrate snack before exercise helps prevent hypoglycemia, especially for clients with type 1 diabetes. The body requires glucose for energy, and exercise can lower blood sugar levels rapidly.
C. Injecting additional insulin before exercising is incorrect. Exercise naturally lowers blood glucose, so adding extra insulin increases the risk of hypoglycemia. Instead, insulin doses may need to be adjusted downward based on activity levels.
D. Avoiding protein before exercising is incorrect. While carbohydrates are the primary concern, protein intake before exercise is not harmful and can support muscle function. However, the focus should be on carbohydrate intake to maintain blood glucose levels.
Correct Answer is D
Explanation
A. “I can make several office visits, so my child does not get so many immunizations at once.”: This is incorrect. It is recommended that children receive multiple immunizations during a single office visit to help ensure they are fully vaccinated on time. Spacing out immunizations is not typically recommended unless there is a specific medical concern.
B. "I understand that immunizations will be withheld if my child has lactose intolerance.": This is incorrect. Lactose intolerance does not contraindicate immunizations. Some vaccines may contain small amounts of lactose, but this does not prevent a child with lactose intolerance from receiving them.
C. "My child will need to start the human papillomavirus series when he enters kindergarten.": This is incorrect. The human papillomavirus (HPV) vaccine is recommended to be started at ages 11 or 12, not when the child enters kindergarten.
D. "It is recommended that my child receive his first flu immunization at the age of 6.": This is correct. The first flu vaccine is recommended for children aged 6 months and older, and the initial flu vaccine may require two doses for children under 9 years of age, spaced at least 4 weeks apart.
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