A client arrives at the emergency department with symptoms of muscle contractions and rigidity in the jaw, neck, back, and abdominal muscles. Which of the following actions by the nurse is appropriate for managing this client's condition? Select all that apply.
Administering antitoxin therapy.
Initiating antibiotic treatment.
Providing muscle relaxants.
Ensuring adequate hydration.
Applying heat to affected areas.
Correct Answer : A,C,D
Choice A rationale:
Administering antitoxin therapy is appropriate for managing tetanus because it helps neutralize the neurotoxin produced by Clostridium tetani and can prevent its further effects on the body.
Choice B rationale:
Initiating antibiotic treatment is not effective in managing tetanus. Antibiotics are not useful in neutralizing the neurotoxin and treating the symptoms of tetanus.
Choice C rationale:
Providing muscle relaxants is essential for managing tetanus, as they help alleviate muscle contractions and rigidity, reducing the severity of symptoms.
Choice D rationale:
Ensuring adequate hydration is crucial in managing tetanus because dehydration can worsen muscle spasms and lead to complications.
Choice E rationale:
Applying heat to affected areas is not appropriate for managing tetanus. Heat application can exacerbate muscle contractions and is not a recommended intervention for this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The statement "Localized tetanus, affecting muscles near the site of infection" is incorrect. Localized tetanus involves muscle spasms near the site of infection, but it is not the most common type of tetanus.
Choice B rationale:
The statement "Generalized tetanus, affecting all skeletal muscles" is correct. Generalized tetanus is the most common type of tetanus and affects all skeletal muscles, leading to widespread muscle spasms and rigidity.
Choice C rationale:
The statement "Cephalic tetanus, affecting only the cranial nerves" is not the most common type of tetanus. Cephalic tetanus is a rare form that involves cranial nerve dysfunction.
Choice D rationale:
The statement "Neonatal tetanus, affecting infants born to non-immunized mothers" is not the most common type of tetanus. Neonatal tetanus occurs in newborns born to inadequately immunized mothers and is also relatively rare compared to generalized tetanus in adults.
Correct Answer is C
Explanation
Choice A rationale:
The statement "Tetanus can be transmitted from person to person through respiratory secretions" is incorrect. Tetanus is not a communicable disease, and it does not spread from person to person.
Choice B rationale:
The statement "The primary reservoir of
C. tetani is contaminated food and water" is incorrect. Tetanus is primarily found in the environment, especially in soil, as
C. tetani is a bacterium that forms spores in the environment.
Choice C rationale:
The correct statement explains that tetanus spores can persist in the environment and enter the body through a wound. This is accurate as
C. tetani spores can survive for years in soil and dust, and they enter the body through cuts, puncture wounds, or other openings in the skin.
Choice D rationale:
The statement "Vector transmission of tetanus occurs primarily through mosquito bites" is incorrect. Tetanus is not transmitted through mosquito bites. Mosquitoes are not carriers of
C. tetani, and the infection does not spread through their bites.
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