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.
Trismus (lockjaw)
Dyspnea (difficulty breathing)
Ptosis (drooping eyelid)
Tachycardia (rapid heart rate)
Risus sardonicus (facial muscle spasm)
Correct Answer : A,B,E
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
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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