A client has a puncture wound caused by a rusty nail. The nurse understands that which of the following should be initiated to prevent tetanus?

Administer antiviral medication.

Provide tetanus antitoxin.

Perform wound debridement.

Apply cold compress to the wound.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Antiviral medications are used to treat viral infections, but tetanus is caused by a bacterium, not a virus. Antiviral medication would not be effective in preventing tetanus.

Choice B rationale:

To prevent tetanus in a person with a puncture wound caused by a rusty nail, providing tetanus antitoxin is essential. The antitoxin can neutralize any tetanus neurotoxin that may have already been produced, preventing its effects on the nervous system.

Choice C rationale:

Wound debridement is the removal of foreign material and dead tissue from a wound, which can help reduce the risk of infection. While important for wound care, it does not specifically prevent tetanus and is not the primary intervention for this case.

Choice D rationale:

Applying a cold compress to the wound can help reduce pain and swelling, but it does not prevent tetanus. The priority is to administer tetanus antitoxin to neutralize the neurotoxin if present.

Choice E rationale:

Anticoagulant therapy is used to prevent or treat blood clotting disorders and is not relevant to preventing tetanus in this scenario.

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Correct Answer is B

Explanation

Choice A rationale:

Malaria is caused by the Plasmodium parasite transmitted through the bite of infected mosquitoes. It is not related to wound contamination with soil and feces.

Choice B rationale:

Tetanus, also known as lockjaw, is caused by the bacterium Clostridium tetani, which is commonly found in soil and feces. When the bacterium enters a wound, it can produce a neurotoxin that affects the nervous system, leading to muscle stiffness and spasms.

Choice C rationale:

Influenza, commonly known as the flu, is caused by influenza viruses and is primarily transmitted through respiratory droplets. It is not related to wound contamination.

Choice D rationale:

Pneumonia is an infection that inflames the air sacs in the lungs, and it is caused by various pathogens, including bacteria, viruses, and fungi. It is not directly linked to wound contamination with soil and feces.

A. Renal impairment. B. Cardiac arrhythmias. C. Aspiration pneumonia. D. Diaphoresis (sweating)

Correct Answer is B

Explanation

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.

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A client has a puncture wound caused by a rusty nail. The nurse understands that which of the following should be initiated to prevent tetanus?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who has a wound contaminated with soil and feces. The nurse understands that this patient is at risk of developing which condition?

Correct Answer is B

Explanation

A nurse is caring for a client with tetanus who experiences muscle spasms triggered by stimuli. Which complication should the nurse be vigilant for in this client?

Correct Answer is B

Explanation

A client with tetanus is receiving antibiotic therapy. Which statement made by the client indicates a need for further education?

A nurse is assessing a client suspected of having localized tetanus. Which statement made by the client is characteristic of this type of tetanus?

(ATI/HESI from external source):A nurse is caring for a client diagnosed with tetanus. The client asks the nurse, "What is the most common type of tetanus?" How should the nurse respond?

A nurse is teaching a community health class about tetanus transmission. Which statement by a participant indicates a correct understanding of the disease transmission?

Which of the following statements about tetanus is accurate?

A client has been diagnosed with generalized tetanus. Which nursing interventions should the nurse prioritize to manage the client's condition effectively? Select all that apply.

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.

A nurse is caring for a client suspected of having tetanus. Which of the following signs and symptoms should the nurse expect to assess in the client? Select all that apply.