A nurse is caring for a client with tetanus who experiences muscle spasms triggered by stimuli. Which complication should the nurse be vigilant for in this client?

Choice A rationale:

The nurse should be vigilant for renal impairment in clients with tetanus. However, muscle spasms triggered by stimuli do not directly indicate renal impairment. The client's renal function should be monitored due to the potential side effects of medications and prolonged immobilization.

Choice B rationale:

The statement "Cardiac arrhythmias" is correct. Muscle spasms triggered by stimuli in tetanus can cause severe and prolonged muscle contractions, which may lead to autonomic instability, including cardiac arrhythmias. Monitoring the client's cardiac function is essential to detect and manage any arrhythmias that may arise.

Choice C rationale:

The nurse should be vigilant for aspiration pneumonia in clients with tetanus. However, muscle spasms triggered by stimuli do not directly indicate the development of aspiration pneumonia. Aspiration pneumonia can occur due to impaired swallowing and a risk of aspiration during muscle spasms.

Choice D rationale:

The statement "Diaphoresis (sweating)" is not directly associated with muscle spasms triggered by stimuli in tetanus. Diaphoresis may occur in response to fever or autonomic dysfunction but is not a primary concern related to the muscle spasms.

Choice A rationale:

Administering antitoxin therapy is appropriate for managing tetanus because it helps neutralize the neurotoxin produced by Clostridium tetani and can prevent its further effects on the body.

Choice B rationale:

Initiating antibiotic treatment is not effective in managing tetanus. Antibiotics are not useful in neutralizing the neurotoxin and treating the symptoms of tetanus.

Choice C rationale:

Providing muscle relaxants is essential for managing tetanus, as they help alleviate muscle contractions and rigidity, reducing the severity of symptoms.

Choice D rationale:

Ensuring adequate hydration is crucial in managing tetanus because dehydration can worsen muscle spasms and lead to complications.

Choice E rationale:

Applying heat to affected areas is not appropriate for managing tetanus. Heat application can exacerbate muscle contractions and is not a recommended intervention for this condition.