When educating a client about tetanus, which of the following will the nurse include in teaching? Select All that Apply

Affects only the spinal cord

Manifestations include sustained muscle contractions

Follows a recent viral infection

Bacteria is found in improperly processed foods

Spores are found in soil, gardens, and manure

Answer and Explanation

Correct Answer : B,E

Choice A Rationale: Tetanus does not affect only the spinal cord; it is a systemic bacterial infection that affects the nervous system and muscles.

Choice B Rationale: Manifestations of tetanus can include sustained muscle contractions, which result in muscle stiffness and spasms.

Choice C Rationale: Tetanus is not caused by a recent viral infection; it is caused by the bacterium Clostridium tetani.

Choice D Rationale: While tetanus can result from contaminated wounds, it is not typically associated with improperly processed foods. It is caused by the spores of the Clostridium tetani bacterium.

Choice E Rationale: Tetanus spores are commonly found in soil, gardens, and manure. Contaminated wounds, especially puncture wounds, are a common route of transmission for the spores.

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Correct Answer is D

Explanation

Choice A Rationale: Documenting an overdose is premature without further assessment and evidence.

Choice B Rationale: Acute dementia is not typically diagnosed based on rapidly fluctuating moods alone, and it may not be appropriate for this situation.

Choice C Rationale: While substance abuse comorbidity may be present, it does not fully capture the client's current presentation.

Choice D Rationale: Documenting acute delirium is appropriate in this case. The client's symptoms, including rapidly fluctuating moods and delusions, are indicative of acute delirium, which can be related to substance withdrawal or other medical issues.

A. Loosen all of the connections on the vest to assess the skin B. Ask about the client's ability to perform range of motion to legs C. Ask how the client is able to reposition self in bed D. Assess the pin sites

Correct Answer is D

Explanation

Choice A Rationale: Loosening all of the connections on the vest to assess the skin is not the first priority and may compromise the stability of the halo brace.

Choice B Rationale: Asking about the client's ability to perform range of motion to legs is important but may not be the first priority.

Choice C Rationale: Asking how the client is able to reposition self in bed is important but may not be the first priority.

Choice D Rationale: Assessing the pin sites is the first priority in caring for a client with a halo brace, as complications related to pin site infections or issues can have significant consequences. Pin site care and assessment are crucial to prevent infections and complications.

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When educating a client about tetanus, which of the following will the nurse include in teaching? Select All that Apply

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Naxlex Comprehensive Predictor Exams

A 45 year old client with a history of drug and alcohol abuse is admitted to the hospital. On day 2 the client has rapidly fluctuating moods and believes the King of England is in his room. How will the nurse document these findings?

Correct Answer is D

Explanation

The nurse is providing care for a client who was placed in a halo brace 2 days ago because of a spinal cord injury. Which assessment is the first priority of the nurse?

Correct Answer is D

Explanation

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