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 D
Explanation
A. Holding the irrigation solution bottle 5 cm (2 in) above the sterile container is incorrect because the solution should be poured into a sterile container without contaminating the sterile field. The nurse should pour the solution from a height that avoids splashing and contamination.
B. Opening the outer wrapper of the sterile package toward her body is incorrect. The outer wrapper of a sterile package should be opened away from the body to avoid contamination of the sterile field.
C. Placing the irrigation solution bottle cap on the sterile field is incorrect. The cap should not be placed on the sterile field, as it may introduce contaminants.
D. Placing sterile objects at least 2.5 cm (1 in) from the edge of the sterile field is correct. This practice maintains the sterility of the field by preventing contamination from external sources.
Correct Answer is C
Explanation
A. “I will follow a full-liquid diet the day before the procedure.": This is incorrect. Typically, clients are instructed to follow a clear-liquid diet the day before a colonoscopy, not a full-liquid diet. Clear liquids (e.g., water, broth, clear juices) are required to ensure the colon is fully cleaned out for the procedure.
B. “This procedure will take place while I'm under general anesthesia.”: This is incorrect. A colonoscopy is usually performed with moderate sedation or conscious sedation, not general anesthesia. The client may be sedated but will not be completely unconscious.
C. “I have my friend drive me home after the procedure.”: This is correct. After a colonoscopy, the sedation used for the procedure can impair the client's ability to drive. It is recommended that the client arrange for a friend or family member to drive them home.
D. “I can expect rectal bleeding for a week after the procedure.”: This is incorrect. Mild rectal bleeding can occur immediately after the procedure, but it should not last for a week. If bleeding persists beyond a day or two, the client should contact their healthcare provider.
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