(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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

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.

A. Administer human tetanus immune globulin (TIG) B. Provide oxygen therapy and suctioning as needed. C. Use padded side rails and restraints to prevent injury. D. Educate the client about completing the vaccination schedule. E. Use non-pharmacological methods for pain management.

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale:

Administering human tetanus immune globulin (TIG) is a priority intervention in the management of generalized tetanus. TIG provides passive immunity and helps neutralize circulating tetanus toxin.

Choice B rationale:

Providing oxygen therapy and suctioning as needed is essential in managing generalized tetanus. Respiratory muscle spasms can lead to breathing difficulties, and supportive measures like oxygen therapy and suctioning can help maintain adequate oxygenation.

Choice C rationale:

Using padded side rails and restraints to prevent injury is not appropriate in the management of tetanus. These measures may increase muscle spasms and worsen the client's condition.

Choice D rationale:

Educating the client about completing the vaccination schedule is essential for prevention. However, in the case of an already diagnosed generalized tetanus, it is not a priority intervention.

Choice E rationale:

Using non-pharmacological methods for pain management is an essential aspect of caring for clients with tetanus. Pain relief measures, such as warm compresses and positioning, can help alleviate muscle spasms and discomfort.

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(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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who sustained a puncture wound from a dirty nail. Which microorganism is responsible for tetanus?

Correct Answer is B

Explanation

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.

Correct Answer is ["A","B","D","E"]

Explanation

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

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

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 assessing a client suspected of having localized tetanus. Which statement made by the client is characteristic of this type of tetanus?

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

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

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.