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.

Choice A rationale:

The nurse should be vigilant for renal impairment in clients with tetanus. However, muscle spasms triggered by stimuli do not directly indicate renal impairment. The client's renal function should be monitored due to the potential side effects of medications and prolonged immobilization.

Choice B rationale:

The statement "Cardiac arrhythmias" is correct. Muscle spasms triggered by stimuli in tetanus can cause severe and prolonged muscle contractions, which may lead to autonomic instability, including cardiac arrhythmias. Monitoring the client's cardiac function is essential to detect and manage any arrhythmias that may arise.

Choice C rationale:

The nurse should be vigilant for aspiration pneumonia in clients with tetanus. However, muscle spasms triggered by stimuli do not directly indicate the development of aspiration pneumonia. Aspiration pneumonia can occur due to impaired swallowing and a risk of aspiration during muscle spasms.

Choice D rationale:

The statement "Diaphoresis (sweating)" is not directly associated with muscle spasms triggered by stimuli in tetanus. Diaphoresis may occur in response to fever or autonomic dysfunction but is not a primary concern related to the muscle spasms.

E.

Choice A rationale:

Trismus, also known as lockjaw, is a hallmark sign of tetanus. It is characterized by the inability to open the mouth due to sustained contraction of the jaw muscles.

Choice B rationale:

Dyspnea, or difficulty breathing, is a possible symptom of tetanus. Tetanus can lead to muscle spasms, including those of the respiratory muscles, which can result in respiratory distress and difficulty breathing.

Choice C rationale:

Ptosis, or drooping eyelid, is not a characteristic sign of tetanus. It is not directly associated with the muscle spasms and rigidity seen in tetanus.

Choice D rationale:

Tachycardia, or rapid heart rate, is not typically associated with tetanus. Tetanus primarily affects the skeletal muscles and does not directly affect the heart rate.

Choice E rationale:

Risus sardonicus, a facial muscle spasm resulting in a sardonic grin-like expression, is a classic sign of tetanus and is caused by sustained contraction of facial muscles.