A nurse is caring for a patient who has a wound contaminated with soil and feces. The nurse understands that this patient is at risk of developing which condition?

Malaria.

Tetanus.

Influenza.

Pneumonia.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Malaria is caused by the Plasmodium parasite transmitted through the bite of infected mosquitoes. It is not related to wound contamination with soil and feces.

Choice B rationale:

Tetanus, also known as lockjaw, is caused by the bacterium Clostridium tetani, which is commonly found in soil and feces. When the bacterium enters a wound, it can produce a neurotoxin that affects the nervous system, leading to muscle stiffness and spasms.

Choice C rationale:

Influenza, commonly known as the flu, is caused by influenza viruses and is primarily transmitted through respiratory droplets. It is not related to wound contamination.

Choice D rationale:

Pneumonia is an infection that inflames the air sacs in the lungs, and it is caused by various pathogens, including bacteria, viruses, and fungi. It is not directly linked to wound contamination with soil and feces.

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Correct Answer is A

Explanation

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.

A. "Localized tetanus, affecting muscles near the site of infection.” B. "Generalized tetanus, affecting all skeletal muscles.” C. "Cephalic tetanus, affecting only the cranial nerves.” D. "Neonatal tetanus, affecting infants born to non-immunized mothers.”

Correct Answer is B

Explanation

Choice A rationale:

The statement "Localized tetanus, affecting muscles near the site of infection" is incorrect. Localized tetanus involves muscle spasms near the site of infection, but it is not the most common type of tetanus.

Choice B rationale:

The statement "Generalized tetanus, affecting all skeletal muscles" is correct. Generalized tetanus is the most common type of tetanus and affects all skeletal muscles, leading to widespread muscle spasms and rigidity.

Choice C rationale:

The statement "Cephalic tetanus, affecting only the cranial nerves" is not the most common type of tetanus. Cephalic tetanus is a rare form that involves cranial nerve dysfunction.

Choice D rationale:

The statement "Neonatal tetanus, affecting infants born to non-immunized mothers" is not the most common type of tetanus. Neonatal tetanus occurs in newborns born to inadequately immunized mothers and is also relatively rare compared to generalized tetanus in adults.

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A nurse is caring for a patient who has a wound contaminated with soil and feces. The nurse understands that this patient is at risk of developing which condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with tetanus presents with difficulty opening their mouth due to jaw muscle spasms. Which statement by the client requires immediate nursing intervention?

Correct Answer is A

Explanation

(ATI/HESI from external source):A nurse is caring for a client diagnosed with tetanus. The client asks the nurse, "What is the most common type of tetanus?" How should the nurse respond?

Correct Answer is B

Explanation

A client has a puncture wound caused by a rusty nail. The nurse understands that which of the following should be initiated to prevent tetanus?

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.

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?

A nurse is caring for a patient who has a wound contaminated with soil and feces. The nurse understands that this patient is at risk of developing which condition?

A client has been diagnosed with generalized tetanus. Which nursing interventions should the nurse prioritize to manage the client's condition effectively? Select all that apply.

A nurse is educating a group of parents about tetanus prevention. Which statement made by a parent indicates a need for further teaching?

(ATI/HESI from external source): A client with tetanus is receiving benzodiazepines for muscle spasms. The nurse knows that benzodiazepines act by:

A client arrives at the emergency department with symptoms of muscle contractions and rigidity in the jaw, neck, back, and abdominal muscles. Which of the following actions by the nurse is appropriate for managing this client's condition? Select all that apply.