A nurse is caring for a patient who sustained a puncture wound from a dirty nail. Which microorganism is responsible for tetanus?
Clostridium difficile.
Clostridium tetani.
Escherichia coli.
Streptococcus pneumoniae.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
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.
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.
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