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 B

Explanation

A. "I can have a meal up to 2 hours before the procedure.": This is not correct. Clients are typically instructed to fast for at least 8 hours before an intravenous pyelogram to ensure clear imaging results and reduce the risk of complications from anesthesia or contrast media.

B. "I will feel a warming sensation after the injection of the dye contrast.": This is correct. It is common for clients to experience a warm sensation when the contrast dye is injected during the procedure.

C. "I do not need to sign a consent form before this procedure.": This is incorrect. A consent form is required before the procedure as it involves the use of contrast dye and potential risks, such as allergic reactions.

D. "I should limit my fluid intake for 2 days after the procedure.": This is not correct. After the procedure, clients are usually encouraged to drink plenty of fluids to help flush the contrast dye from the body and prevent potential kidney complications.

A. The telephone numbers of the clients B. The room numbers of the clients C. The diagnoses of the clients D. The names of the clients' nearest relatives

Correct Answer is A

Explanation

A. Using the telephone numbers of the clients is correct. According to The Joint Commission's National Patient Safety Goals, at least two unique identifiers, such as date of birth and telephone number, should be used to verify client identity before administering medications to prevent errors.

B. Using the room numbers of the clients is incorrect. Room numbers can change, and relying on them increases the risk of medication errors if a client is moved or misidentified.

C. Using the diagnoses of the clients is incorrect. A diagnosis is not a unique identifier, as multiple clients in a unit may have the same or similar conditions, leading to potential confusion.

D. Using the names of the clients' nearest relatives is incorrect. Family members’ names do not provide a direct, unique way to verify the client’s identity, making them unreliable for medication administration.

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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

Naxlex Comprehensive Predictor Exams

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