Tetanus
Tetanus ( 16 Questions)
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.
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.
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.
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 "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.