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. A client who has a sodium intake of 1,200 mg/day.: A sodium intake of 1,200 mg/day is actually within the recommended range for most adults. Therefore, this client does not require a dietitian’s consultation based on this information alone.
B. A client who has a serum albumin level of 4.5 g/dL.: A serum albumin level of 4.5 g/dL is within the normal reference range. There is no immediate concern with this level, so an interprofessional care conference is not necessary for this client.
C. A client who has a body mass index of 32.: A BMI of 32 is classified as obese, which can increase the risk of various health problems. A dietitian’s input can help address dietary modifications to manage weight and improve health outcomes, making an interprofessional care conference appropriate.
D. A client who has a total fat intake of 25% of daily calories.: A fat intake of 25% is within the acceptable range for most adults and does not immediately warrant a referral to a dietitian unless there are other concerns.
Correct Answer is B
Explanation
A. "Communicate with personnel about the need for prophylaxis" is incorrect. While it is important to consider prophylaxis for those who may have been exposed to tuberculosis, the first priority is to minimize the risk of transmission from the client to others.
B. "Place a mask on the client" is correct. Placing a mask on the client is the first step in preventing the spread of tuberculosis. This helps contain respiratory droplets that could transmit the bacteria to others.
C. "Contact those who live with the client" is incorrect. While it is important to contact close contacts to assess their risk, this action comes after implementing infection control measures, such as placing a mask on the client.
D. "Notify the local health department" is incorrect. While the health department must be notified about a tuberculosis diagnosis, the immediate priority is to protect others from exposure by masking the client and using appropriate isolation precautions.
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