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.
Administer human tetanus immune globulin (TIG)
Provide oxygen therapy and suctioning as needed.
Use padded side rails and restraints to prevent injury.
Educate the client about completing the vaccination schedule.
Use non-pharmacological methods for pain management.
Correct Answer : A,B,D,E
E.
Choice A rationale:
Administering human tetanus immune globulin (TIG) is a priority intervention in the management of generalized tetanus. TIG provides passive immunity and helps neutralize circulating tetanus toxin.
Choice B rationale:
Providing oxygen therapy and suctioning as needed is essential in managing generalized tetanus. Respiratory muscle spasms can lead to breathing difficulties, and supportive measures like oxygen therapy and suctioning can help maintain adequate oxygenation.
Choice C rationale:
Using padded side rails and restraints to prevent injury is not appropriate in the management of tetanus. These measures may increase muscle spasms and worsen the client's condition.
Choice D rationale:
Educating the client about completing the vaccination schedule is essential for prevention. However, in the case of an already diagnosed generalized tetanus, it is not a priority intervention.
Choice E rationale:
Using non-pharmacological methods for pain management is an essential aspect of caring for clients with tetanus. Pain relief measures, such as warm compresses and positioning, can help alleviate muscle spasms and discomfort.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The correct statement indicates the need for a tetanus booster every 10 years during adulthood. This aligns with current guidelines as the immunity from tetanus vaccination can wane over time, necessitating booster doses.
Choice B rationale:
The correct statement explains that tetanus can be prevented by proper wound care and keeping the wound clean. This is accurate because tetanus spores are commonly found in soil and can enter the body through contaminated wounds, making wound care crucial for prevention.
Choice C rationale:
The correct statement indicates a need for further teaching as it is incorrect. Tetanus is not transmitted through respiratory droplets. Tetanus is caused by the Clostridium tetani bacterium found in the environment, especially in soil, and it enters the body through wounds, not through respiratory secretions.
Choice D rationale:
The correct statement highlights that tetanus is more common in developing countries due to lower immunization rates. This is accurate since immunization plays a significant role in preventing tetanus, and lower vaccination rates in some regions contribute to higher disease incidence.
Correct Answer is A
Explanation
Choice A rationale:
Benzodiazepines act by enhancing the effects of gamma-aminobutyric acid (GABA) in the central nervous system (CNS) GABA is an inhibitory neurotransmitter that reduces neural activity, leading to sedation and muscle relaxation. By enhancing GABA's effects, benzodiazepines help relieve muscle spasms in clients with tetanus.
Choice B rationale:
Blocking the release of acetylcholine at neuromuscular junctions is not the mechanism of action of benzodiazepines. This statement is incorrect.
Choice C rationale:
Inhibiting the action of excitatory neurotransmitters in the brain is not the primary mechanism of action of benzodiazepines. They primarily enhance the activity of inhibitory neurotransmitters like GABA.
Choice D rationale:
Stimulating the production of dopamine in the spinal cord is not a mechanism of action for benzodiazepines. This statement is inaccurate.
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