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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
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.
Correct Answer is ["A","B","E"]
Explanation
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.
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