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: Hemiplegia involves paralysis of one side of the body and is typically associated with brain injuries or lesions, not spinal cord injuries.

Choice B Rationale: Quadriplegia involves paralysis of all four limbs and is more commonly associated with higher spinal cord injuries, not T2-T3.

Choice C Rationale: Paresthesia refers to abnormal sensations, such as tingling or numbness, and may be present in various spinal cord injuries, but it is not a type of disability.

Choice D Rationale: Paraplegia involves paralysis of the lower extremities and trunk, and it is commonly associated with spinal cord injuries at the T2-T3 level.

A. Assess the client for bladder distention. B. Lay the client flat C. Obtain the client's heart rate. D. Administer a nitrate antihypertensive.

Correct Answer is A

Explanation

Choice A Rationale: Assessing the client for bladder distention is the first and most crucial step in managing autonomic dysreflexia. Bladder distention is a common trigger for this condition in clients with spinal cord injuries. Identifying and addressing the cause (bladder distention) is the priority to prevent further complications.

Choice B Rationale: Laying the client flat may not resolve the underlying cause of autonomic dysreflexia and should be done after identifying and addressing the trigger.

Choice C Rationale: Obtaining the client's heart rate is important but should come after assessing for bladder distention since the primary concern in autonomic dysreflexia is elevated blood pressure due to a noxious stimulus.

Choice D Rationale: Administering a nitrate antihypertensive may be necessary if other interventions do not resolve the blood pressure elevation, but it should not be the first action. Identifying and addressing the cause, such as bladder distention, is the priority.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

Correct Answer is D

Explanation

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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