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    Ati Demsn 650 Pediatrics Proctored Exam

    A 5-year-old child presents to the emergency department with a stiff jaw, muscle spasms, and difficulty swallowing. The mother reports the child stepped on rusty nail 10 days ago. Which of the following is the priority nursing intervention?

    Explanation & Rationale

    A. While cold compresses can reduce local pain and inflammation, they do not address the systemic risk of tetanus. Given the child’s symptoms (stiff jaw, muscle spasms, difficulty swallowing) 10 days after stepping on a rusty nail, tetanus is suspected, and simply treating the wound locally is insufficient. B. Muscle stiffness and spasms in tetanus are caused by neurotoxin effects on the nervous system, not inactivity. Ambulation does not prevent the progression of tetanus and could increase the risk of falls or injury. C. The child’s clinical presentation is consistent with tetanus, which is a medical emergency. The priority intervention is to neutralize the toxin and provide active and passive immunization. The tetanus booster stimulates active immunity, while tetanus immune globulin (TIG) provides immediate passive immunity to neutralize circulating toxin. This intervention is life-saving and takes priority over local wound care or antibiotics. D. Antibiotics like metronidazole or penicillin are used to reduce bacterial load, but they do not neutralize circulating tetanus toxin and are secondary to immediate immunotherapy. Delaying TIG while focusing only on antibiotics could be fatal.

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