Author Question: The nurse identifies a patient with a repeating pattern of muscle contraction of the leg for 5 ... (Read 86 times)

javeds · **on:** Jul 23, 2018

The nurse identifies a patient with a repeating pattern of muscle contraction of the leg for 5 seconds followed by 2 seconds of relaxation as experiencing

1. a clonic spasm.
2. a tonic spasm.
3. spasticity.
4. dystonia.

Question 2

A mother brings her child to the clinic for his last diphtheria-pertussis-tetanus (DPT) immunization. The mother tells the nurse that the child developed a red rash after the previous diphtheria-pertussis-tetanus (DPT) immunization. What does the best action by the nurse include?

1. Administer only a pertussis-tetanus immunization.
2. Withhold this immunization and contact the physician.
3. Tell the mother to give the child acetaminophen (Tylenol) if another rash develops.
4. Administer diphenhydramine (Benadryl) prior to the diphtheria-pertussis-tetanus (DPT) immunization.

cici · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

1
Rationale 1: Clonic muscle spasms involve multiple, rapidly repeated contractions.
Rationale 2: Tonic spasms involve a single prolonged contraction.
Rationale 3: Spasticity involves a continuous state of contraction.
Rationale 4: Dystonia is a chronic neurological disorder that can cause spasticity.
Global Rationale: Clonic muscle spasms involve multiple, rapidly repeated contractions. Tonic spasms involve a single prolonged contraction. Spasticity involves a continuous state of contraction, and dystonia is a chronic neurological disorder that can cause spasticity.

Answer to Question 2

2
Rationale 1: There is no such immunization as pertussis-tetanus.
Rationale 2: This red rash is unexpected and could indicate a potential adverse reaction to the vaccine such as anaphylaxis, so the nurse should withhold the immunization and contact the physician.
Rationale 3: The nurse should not tell the mother to administer acetaminophen (Tylenol); this will not prevent anaphylaxis.
Rationale 4: The nurse cannot administer diphenhydramine (Benadryl) without a physician's order.
Global Rationale: This red rash is unexpected and could indicate a potential adverse reaction to the vaccine such as anaphylaxis, so the nurse should withhold the immunization and contact the physician. There is no such immunization as pertussis-tetanus. The nurse should not tell the mother to administer acetaminophen (Tylenol); this will not prevent anaphylaxis. The nurse cannot administer diphenhydramine (Benadryl) without a physician's order.