(ATI/HESI from external source): A nurse is caring for a client with generalized tetanus. The client is experiencing spasms triggered by stimuli. Which nursing intervention is the priority?
Administer human tetanus immune globulin (TIG)
Provide oxygen therapy and suctioning as needed.
Educate the client about completing the vaccination schedule.
Use non-pharmacological methods for pain management.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is B
Explanation
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.
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