For a client admitted with a diagnosis of tetanus, which clinical indicators should the nurse assess? Select all that apply.

When assessing a client with a diagnosis of tetanus, it is essential to focus on key clinical indicators that are characteristic of the condition. Muscular rigidity is one of the hallmark signs of tetanus. This occurs due to the action of the tetanospasmin toxin produced by the Clostridium tetani bacteria, which affects the central nervous system and leads to sustained contraction of the muscles.

Additionally, spastic voluntary muscle contractions are indicative of the tetanic spasms that patients experience. These spasms are often triggered by stimuli and can be severe, contributing to the overall presentation of tetanus. Both muscular rigidity and spastic contractions are critical signs that healthcare professionals monitor in the management of this potentially life-threatening condition.

While restlessness and fever can occur in various clinical scenarios, they are not specific indicators of tetanus. Restlessness might be a response to discomfort or anxiety, while fever could be indicative of an infection elsewhere in the body. Therefore, recognizing and assessing muscular rigidity and spastic muscle contractions are vital for understanding the patient's condition and planning appropriate interventions in tetanus management.