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 A
Explanation
A. Assist with a referral to a home health care agency is correct. If the client has no one to assist them at home after surgery, a home health care agency can provide the necessary support. This is a proactive solution to ensure the client has assistance for postoperative recovery, including monitoring for complications, assistance with mobility, and other care needs.
B. Calling the provider about admitting the client to the facility overnight is incorrect. Outpatient surgery is typically intended for clients who can recover at home, and there is no indication that the client requires overnight admission based solely on the lack of assistance at home.
C. Giving the client a list of home care assistants to contact is incorrect. While this could be helpful, it is the nurse's role to actively assist in arranging care. Referring the client to a list of names without offering concrete help may leave the client in a challenging situation.
D. Contacting the next of kin to assist the client at home is incorrect. Although contacting a relative may be an option, it may not be viable or practical for the client. Home health care offers a more reliable solution, as family members may not always be available to provide consistent care.
Correct Answer is B
Explanation
A. Store the dentures in a dry denture cup on the bedside table after cleaning.: Dentures should not be stored in a dry cup as this can lead to drying out and warping of the dentures. They should be stored in water or a denture solution to keep them moist.
B. Place a towel in the sink when cleaning the dentures.: This is correct. Placing a towel in the sink is a safety precaution to prevent dentures from breaking if they are accidentally dropped while being cleaned. It also helps prevent damage from impact with hard surfaces.
C. Remove the lower dentures before the upper dentures.: There is no specific order required for removing dentures, as both upper and lower dentures should be removed carefully and cleaned.
D. Use a circular motion to cleanse the biting surface of the dentures.: A circular motion is not the best technique for cleaning dentures. Instead, the dentures should be brushed gently with a soft toothbrush, focusing on cleaning all surfaces, including the biting surfaces, using a back-and-forth motion.
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