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. "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.

A. Give a dose of alendronate. B. Administer furosemide. C. Apply a cardiac monitor. D. Monitor for Chvostek's sign.

Correct Answer is C

Explanation

A. Give a dose of alendronate is incorrect. Alendronate is a medication used to treat osteoporosis, and it does not address low potassium levels. In this case, the focus should be on correcting the potassium imbalance.

B. Administer furosemide is incorrect. Furosemide is a diuretic that can cause further loss of potassium. In a client with low potassium levels (hypokalemia., administering furosemide could worsen the condition and lead to life-threatening complications.

C. Apply a cardiac monitor is correct. Hypokalemia (potassium level of 2.9 mEq/L) can cause significant cardiac arrhythmias, including ventricular tachycardia or fibrillation. Applying a cardiac monitor is essential for monitoring the client’s heart rhythm and detecting any abnormalities related to the low potassium level.

D. Monitor for Chvostek's sign is incorrect. Chvostek's sign is indicative of hypocalcemia, not hypokalemia. While both hypocalcemia and hypokalemia can cause neuromuscular excitability, monitoring for Chvostek’s sign is not a priority in the management of hypokalemia.

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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

A nurse in a provider's office is collecting data from a client who was just diagnosed with tuberculosis. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a client who has a potassium level of 2.9 mEq/L. Which of the following actions should the nurse plan?

Correct Answer is C

Explanation

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