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 A

Explanation

A. “Discontinue the medication. I will ask your provider for another antibiotic.”: This is correct. Ciprofloxacin and other fluoroquinolones are associated with a risk of tendonitis and tendon rupture, particularly in the Achilles tendon. The pain in the calf muscle could indicate this side effect. The nurse should recommend discontinuing the medication and notifying the provider for further evaluation.

B. “That reaction means your dose is too high. Cut the pill in half.”: This is incorrect. The pain in the calf muscle is likely related to a known side effect of ciprofloxacin, rather than the dose being too high. Adjusting the dose is not the appropriate solution.

C. “Continue to take the medication. Calf pain is a minor reaction that will resolve itself.”: This is incorrect. Calf pain may be indicative of a serious side effect, such as tendonitis or tendon rupture, and the medication should be discontinued until the provider evaluates the client.

D. “This is an allergic reaction. Take the medication with an antihistamine.”: This is incorrect. The pain in the calf muscle is more likely due to tendon-related side effects, not an allergic reaction. Ciprofloxacin-related tendon pain requires immediate attention, and antihistamines would not address the underlying issue.

A. Take the medication and then lay down for 30 min. B. Take the medication with an antacid. C. Take the medication with calcium-fortified orange juice. D. Take the medication with crackers.

Correct Answer is D

Explanation

A. "Take the medication and then lay down for 30 min.": This is not recommended. Lying down after taking doxycycline can increase the risk of esophageal irritation and ulceration. It is best to remain upright for at least 30 minutes after taking the medication.

B. "Take the medication with an antacid.": This is incorrect. Antacids can interfere with the absorption of doxycycline and reduce its effectiveness. It is important to avoid antacids, calcium supplements, and iron supplements within 2 hours of taking doxycycline.

C. "Take the medication with calcium-fortified orange juice.": This is incorrect. Calcium can bind with doxycycline, reducing its absorption and effectiveness. It is best to avoid taking doxycycline with calcium-rich products like milk or fortified juices.

D. "Take the medication with crackers.": This is correct. Taking doxycycline with a small amount of food, like crackers, can help reduce gastrointestinal discomfort, such as nausea and vomiting. It is recommended to take doxycycline with food if nausea occurs, though not with dairy or antacids.

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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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Explanation

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Explanation

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