When caring for the client hospitalized with tetanus, which of the following will the nurse include in the care plan?
Educate about the importance of proper food handling
Offer food at least 4 times a day
Anticipate administration of opioids
Provide distraction activities
The Correct Answer is C
Choice A Rationale: Educating about the importance of proper food handling is important for preventing foodborne illnesses but is not specific to the care of a client with tetanus.
Choice B Rationale: Offering food at least 4 times a day may be necessary for maintaining nutritional support, but it does not address the specific care needs of a client with tetanus.
Choice C Rationale: Anticipating administration of opioids is an important component of the care plan for tetanus. Opioids can help manage muscle spasms and severe pain associated with tetanus.
Choice D Rationale: Providing distraction activities may be beneficial for clients with tetanus to help divert their attention from muscle spasms and discomfort, but it is not the primary intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Choice A Rationale: Stage 3 of Alzheimer's disease is characterized by increased memory deficits, but the behavior of filling in information with made-up stories is more commonly associated with the earlier stages.
Choice B Rationale: Stage 2 of Alzheimer's disease involves progressive cognitive decline but may not necessarily manifest with the specific behavior described.
Choice C Rationale: Stage 1 of Alzheimer's disease typically has mild cognitive changes, but the behavior mentioned is more indicative of the later stages.
Choice D Rationale: The early stage of Alzheimer's disease may involve the emergence of confabulation, where clients fill in gaps in memory with fabricated stories or information.
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