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.

Choice A rationale:

Administering antitoxin therapy is appropriate for managing tetanus because it helps neutralize the neurotoxin produced by Clostridium tetani and can prevent its further effects on the body.

Choice B rationale:

Initiating antibiotic treatment is not effective in managing tetanus. Antibiotics are not useful in neutralizing the neurotoxin and treating the symptoms of tetanus.

Choice C rationale:

Providing muscle relaxants is essential for managing tetanus, as they help alleviate muscle contractions and rigidity, reducing the severity of symptoms.

Choice D rationale:

Ensuring adequate hydration is crucial in managing tetanus because dehydration can worsen muscle spasms and lead to complications.

Choice E rationale:

Applying heat to affected areas is not appropriate for managing tetanus. Heat application can exacerbate muscle contractions and is not a recommended intervention for this condition.

Choice A rationale:

The correct statement indicates the need for a tetanus booster every 10 years during adulthood. This aligns with current guidelines as the immunity from tetanus vaccination can wane over time, necessitating booster doses.

Choice B rationale:

The correct statement explains that tetanus can be prevented by proper wound care and keeping the wound clean. This is accurate because tetanus spores are commonly found in soil and can enter the body through contaminated wounds, making wound care crucial for prevention.

Choice C rationale:

The correct statement indicates a need for further teaching as it is incorrect. Tetanus is not transmitted through respiratory droplets. Tetanus is caused by the Clostridium tetani bacterium found in the environment, especially in soil, and it enters the body through wounds, not through respiratory secretions.

Choice D rationale:

The correct statement highlights that tetanus is more common in developing countries due to lower immunization rates. This is accurate since immunization plays a significant role in preventing tetanus, and lower vaccination rates in some regions contribute to higher disease incidence.

Choice A rationale:

The statement "I feel my muscles getting stiffer and more painful" requires immediate nursing intervention. These symptoms suggest an exacerbation of tetanus infection, and the client might be experiencing muscle spasms and rigidity that can lead to respiratory compromise.

Choice B rationale:

The statement "I accidentally cut myself while gardening a few days ago" is relevant but doesn't require immediate intervention. It helps the nurse understand a potential source of the tetanus infection, but urgent nursing actions are not necessary based on this statement alone.

Choice C rationale:

The statement "I received a tetanus booster shot about five years ago" indicates that the client has had recent immunization, which is important information but doesn't demand immediate nursing intervention.

Choice D rationale:

The statement "I've been experiencing some difficulty swallowing" should be monitored, but it doesn't need immediate intervention unless it worsens and compromises the airway.

Choice A rationale:

The statement "Tetanus can be transmitted from person to person through respiratory secretions" is incorrect. Tetanus is not a communicable disease, and it does not spread from person to person.

Choice B rationale:

The statement "The primary reservoir of

C. tetani is contaminated food and water" is incorrect. Tetanus is primarily found in the environment, especially in soil, as

C. tetani is a bacterium that forms spores in the environment.

Choice C rationale:

The correct statement explains that tetanus spores can persist in the environment and enter the body through a wound. This is accurate as

C. tetani spores can survive for years in soil and dust, and they enter the body through cuts, puncture wounds, or other openings in the skin.

Choice D rationale:

The statement "Vector transmission of tetanus occurs primarily through mosquito bites" is incorrect. Tetanus is not transmitted through mosquito bites. Mosquitoes are not carriers of

C. tetani, and the infection does not spread through their bites.

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.

Choice A rationale:

Tetanus is not commonly transmitted from person to person. Instead, it is usually acquired through the introduction of the Clostridium tetani bacterium into a wound, where it can produce the neurotoxin tetanospasmin.

Choice B rationale:

Tetanus is not effectively treated with antibiotics alone. Antibiotics can help control the infection caused by Clostridium tetani, but the primary treatment involves providing tetanus antitoxin to neutralize the neurotoxin already present in the body.

Choice C rationale:

Booster doses of tetanus vaccine are not recommended every 5 years. The standard recommendation is to receive a tetanus booster every 10 years to maintain protection against the disease.

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.

E.

Choice A rationale:

Trismus, also known as lockjaw, is a hallmark sign of tetanus. It is characterized by the inability to open the mouth due to sustained contraction of the jaw muscles.

Choice B rationale:

Dyspnea, or difficulty breathing, is a possible symptom of tetanus. Tetanus can lead to muscle spasms, including those of the respiratory muscles, which can result in respiratory distress and difficulty breathing.

Choice C rationale:

Ptosis, or drooping eyelid, is not a characteristic sign of tetanus. It is not directly associated with the muscle spasms and rigidity seen in tetanus.

Choice D rationale:

Tachycardia, or rapid heart rate, is not typically associated with tetanus. Tetanus primarily affects the skeletal muscles and does not directly affect the heart rate.

Choice E rationale:

Risus sardonicus, a facial muscle spasm resulting in a sardonic grin-like expression, is a classic sign of tetanus and is caused by sustained contraction of facial muscles.

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:

The statement "I have difficulty opening my mouth due to muscle spasms" is characteristic of localized tetanus. In localized tetanus, muscle spasms are limited to the area near the site of infection or injury, and in this case, it affects the muscles around the mouth, leading to trismus or lockjaw.

Choice B rationale:

Involuntary laughter during muscle spasms is not characteristic of localized tetanus. It is not a typical sign or symptom of the condition.

Choice C rationale:

Arching of the back and difficulty breathing are characteristic signs of generalized tetanus, not localized tetanus. Generalized tetanus involves widespread muscle spasms, including those of the respiratory muscles.

Choice D rationale:

Facial muscle paralysis and slurred speech are not characteristic of localized tetanus. These symptoms are more commonly seen in conditions affecting the cranial nerves or other neurological disorders.

Choice A rationale:

The statement "I should complete the full course of antibiotics as prescribed" is correct. Completing the full course of antibiotics is essential to ensure that all the bacteria causing the infection are eradicated. Stopping antibiotics prematurely may lead to antibiotic resistance and treatment failure.

Choice B rationale:

The statement "The antibiotics will kill the bacteria causing the disease" is correct. Antibiotics are prescribed to kill the bacteria responsible for causing the infection, including tetanus. This is essential in controlling the spread and severity of the disease.

Choice C rationale:

The statement "Antibiotics will help neutralize the toxin in my blood" is incorrect. Antibiotics are effective against bacteria but do not neutralize the toxin produced by the tetanus bacteria. To manage the symptoms of tetanus, other supportive treatments like tetanus antitoxin and muscle relaxants are used to counteract the toxin's effects.

Choice D rationale:

The statement "Penicillin G has a broader spectrum of activity than metronidazole" is irrelevant to the client's tetanus treatment. While it is true that different antibiotics have different spectrums of activity, this information is not relevant to the client's current condition or treatment.

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.

Choice A rationale:

The statement "Localized tetanus, affecting muscles near the site of infection" is incorrect. Localized tetanus involves muscle spasms near the site of infection, but it is not the most common type of tetanus.

Choice B rationale:

The statement "Generalized tetanus, affecting all skeletal muscles" is correct. Generalized tetanus is the most common type of tetanus and affects all skeletal muscles, leading to widespread muscle spasms and rigidity.

Choice C rationale:

The statement "Cephalic tetanus, affecting only the cranial nerves" is not the most common type of tetanus. Cephalic tetanus is a rare form that involves cranial nerve dysfunction.

Choice D rationale:

The statement "Neonatal tetanus, affecting infants born to non-immunized mothers" is not the most common type of tetanus. Neonatal tetanus occurs in newborns born to inadequately immunized mothers and is also relatively rare compared to generalized tetanus in adults.

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.

Choice A rationale:

Benzodiazepines act by enhancing the effects of gamma-aminobutyric acid (GABA) in the central nervous system (CNS) GABA is an inhibitory neurotransmitter that reduces neural activity, leading to sedation and muscle relaxation. By enhancing GABA's effects, benzodiazepines help relieve muscle spasms in clients with tetanus.

Choice B rationale:

Blocking the release of acetylcholine at neuromuscular junctions is not the mechanism of action of benzodiazepines. This statement is incorrect.

Choice C rationale:

Inhibiting the action of excitatory neurotransmitters in the brain is not the primary mechanism of action of benzodiazepines. They primarily enhance the activity of inhibitory neurotransmitters like GABA.

Choice D rationale:

Stimulating the production of dopamine in the spinal cord is not a mechanism of action for benzodiazepines. This statement is inaccurate.

Chickenpox/Shingles.

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