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 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.
Correct Answer is C
Explanation
Choice A rationale:
The statement "I should complete the full course of antibiotics as prescribed" is correct. Completing the full course of antibiotics is essential to ensure that all the bacteria causing the infection are eradicated. Stopping antibiotics prematurely may lead to antibiotic resistance and treatment failure.
Choice B rationale:
The statement "The antibiotics will kill the bacteria causing the disease" is correct. Antibiotics are prescribed to kill the bacteria responsible for causing the infection, including tetanus. This is essential in controlling the spread and severity of the disease.
Choice C rationale:
The statement "Antibiotics will help neutralize the toxin in my blood" is incorrect. Antibiotics are effective against bacteria but do not neutralize the toxin produced by the tetanus bacteria. To manage the symptoms of tetanus, other supportive treatments like tetanus antitoxin and muscle relaxants are used to counteract the toxin's effects.
Choice D rationale:
The statement "Penicillin G has a broader spectrum of activity than metronidazole" is irrelevant to the client's tetanus treatment. While it is true that different antibiotics have different spectrums of activity, this information is not relevant to the client's current condition or treatment.
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