(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?

E.

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.

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.