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.
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Correct Answer is D
Explanation
A. Copy of the client's advance directives: While advance directives are important documents, they are typically filed with the medical record, not specifically included in postmortem documentation. The focus for postmortem documentation is on the body and relevant events surrounding the death.
B. Cause of the client's death.: The cause of death is typically recorded in the official death certificate, which is not part of postmortem nursing documentation. The nurse should not make a diagnosis about the cause of death but may note any relevant findings.
C. Last set of the client's vital signs: Vital signs taken at the time of death may be noted as part of the clinical documentation, but they are not specifically part of postmortem documentation. The postmortem documentation should focus on observations regarding the body and its condition.
D. Location of the identification tag on the client’s body: The nurse should document the location of identification tags on the body to ensure proper identification and to prevent confusion or errors in postmortem care. This is an important detail in postmortem documentation.
Correct Answer is B
Explanation
A. "It takes 2 months of scheduled use before this medication is effective." is incorrect. Montelukast is generally effective within 1-2 weeks of starting the medication, not 2 months.
B. "I will give this medication to my child once daily in the evening." is correct. Montelukast is usually administered once daily, in the evening, to help prevent asthma symptoms.
C. "I can stop giving my child this medication if he is taking a steroid." is incorrect. Montelukast and steroids can be used together to manage asthma, but stopping montelukast is not recommended unless advised by the healthcare provider.
D. "I will give this medication to my child every 2 hours if he is wheezing." is incorrect. Montelukast is a maintenance medication and should not be used as a rescue treatment for acute wheezing. For acute symptoms, a short-acting bronchodilator is typically used.
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