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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Chickenpox/Shingles.
.
Correct Answer is C
Explanation
Choice A rationale:
The statement "Tetanus can be transmitted from person to person through respiratory secretions" is incorrect. Tetanus is not a communicable disease, and it does not spread from person to person.
Choice B rationale:
The statement "The primary reservoir of
C. tetani is contaminated food and water" is incorrect. Tetanus is primarily found in the environment, especially in soil, as
C. tetani is a bacterium that forms spores in the environment.
Choice C rationale:
The correct statement explains that tetanus spores can persist in the environment and enter the body through a wound. This is accurate as
C. tetani spores can survive for years in soil and dust, and they enter the body through cuts, puncture wounds, or other openings in the skin.
Choice D rationale:
The statement "Vector transmission of tetanus occurs primarily through mosquito bites" is incorrect. Tetanus is not transmitted through mosquito bites. Mosquitoes are not carriers of
C. tetani, and the infection does not spread through their bites.
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