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

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.

Choice A rationale:

Administering human tetanus immune globulin (TIG) is the priority intervention for a client with generalized tetanus experiencing spasms triggered by stimuli. TIG provides passive immunity by neutralizing the tetanus toxin and preventing its further action. It is essential to administer TIG promptly to halt the progression of the disease and minimize its complications.

Choice B rationale:

While providing oxygen therapy and suctioning as needed are important nursing interventions, they are not the priority in this situation. These interventions are supportive measures that can help maintain respiratory function but do not directly address the underlying cause of tetanus.

Choice C rationale:

Educating the client about completing the vaccination schedule is important for future prevention, but it is not the priority at this moment. The client is already infected with tetanus, and immediate treatment with TIG takes precedence.

Choice D rationale:

Using non-pharmacological methods for pain management may be helpful, but it is not the priority intervention for a client with generalized tetanus experiencing spasms triggered by stimuli. The priority is to administer TIG to counteract the effects of the tetanus toxin.