A client with tetanus presents with difficulty opening their mouth due to jaw muscle spasms. Which statement by the client requires immediate nursing intervention?
"I feel my muscles getting stiffer and more painful.”
"I accidentally cut myself while gardening a few days ago.”
"I received a tetanus booster shot about five years ago.”
"I've been experiencing some difficulty swallowing.”
The Correct Answer is A
Choice A rationale:
The statement "I feel my muscles getting stiffer and more painful" requires immediate nursing intervention. These symptoms suggest an exacerbation of tetanus infection, and the client might be experiencing muscle spasms and rigidity that can lead to respiratory compromise.
Choice B rationale:
The statement "I accidentally cut myself while gardening a few days ago" is relevant but doesn't require immediate intervention. It helps the nurse understand a potential source of the tetanus infection, but urgent nursing actions are not necessary based on this statement alone.
Choice C rationale:
The statement "I received a tetanus booster shot about five years ago" indicates that the client has had recent immunization, which is important information but doesn't demand immediate nursing intervention.
Choice D rationale:
The statement "I've been experiencing some difficulty swallowing" should be monitored, but it doesn't need immediate intervention unless it worsens and compromises the airway.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The statement "I have difficulty opening my mouth due to muscle spasms" is characteristic of localized tetanus. In localized tetanus, muscle spasms are limited to the area near the site of infection or injury, and in this case, it affects the muscles around the mouth, leading to trismus or lockjaw.
Choice B rationale:
Involuntary laughter during muscle spasms is not characteristic of localized tetanus. It is not a typical sign or symptom of the condition.
Choice C rationale:
Arching of the back and difficulty breathing are characteristic signs of generalized tetanus, not localized tetanus. Generalized tetanus involves widespread muscle spasms, including those of the respiratory muscles.
Choice D rationale:
Facial muscle paralysis and slurred speech are not characteristic of localized tetanus. These symptoms are more commonly seen in conditions affecting the cranial nerves or other neurological disorders.
Correct Answer is B
Explanation
Choice B rationale:
Clostridium tetani is responsible for tetanus. When a puncture wound is contaminated with spores of this bacterium, it can produce a potent neurotoxin that causes muscle contractions, rigidity, and potentially life-threatening complications.
Choice A rationale:
Clostridium difficile is not responsible for tetanus. It is a different bacterium that can cause gastrointestinal infections and antibiotic-associated diarrhea.
Choice C rationale:
Escherichia coli is not responsible for tetanus. While certain strains of
E. coli can cause food poisoning and other infections, it is not associated with tetanus.
Choice D rationale:
Streptococcus pneumoniae is not responsible for tetanus. It is a bacterium commonly associated with respiratory infections, such as pneumonia.
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