Which action will the nurse take when caring for a 46-year-old patient who develops tetanus from an injectable substance use?
a. Avoid use of sedatives.
b. Provide a quiet environment.
c. Check pupil reaction to light every 4 hours.
d. Provide range-of-motion exercises several times daily.
ANS: B
In patients with tetanus, painful seizures can be precipitated by jarring, loud noises, or bright lights, so the nurse will minimize noise and avoid shining light into the patient's eyes. Range-of-motion exercises may also stimulate the patient and cause seizures. Although the patient has a history of injectable drug use, sedative medications will be needed to decrease spasms.
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