The nurse is caring for a client who has had a stroke and who has received tissue plasminogen activator (t-PA) on admission. The family member requests to bring in a razor for the client to use. Which response from the family would indicate an understanding teaching related to t-PA? The family member states, "I will
be careful with the straight razor."
insist the nurse use multiple razor blades."
bring in an electric razor for nurse to use for shaving."
bring in disposable razors blades to use for, shaving."
The Correct Answer is C
A. This response shows some awareness but does not indicate a sufficient understanding of the risks. Straight razors can pose a significant risk of cuts and bleeding, especially in a patient who has received t- PA, which can increase the likelihood of bleeding.
B. This response suggests a misunderstanding. Using multiple razor blades does not inherently reduce the risk of bleeding and could increase the chance of cuts or nicks. This response does not indicate an appropriate understanding of safety precautions related to t-PA.
C. This response indicates an understanding of safety precautions. Electric razors are safer for clients who are at risk of bleeding because they do not have sharp blades that can easily cause cuts. This choice minimizes the risk of injury while allowing for personal grooming.
D. While disposable razors may seem convenient, they still carry a risk of cuts and bleeding. This response does not reflect a full understanding of the precautions necessary for a client who has received t-PA, as it does not prioritize safety in the same way that using an electric razor does.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This statement is not advisable. While it is essential to avoid strenuous activity initially, gentle arm exercises and range-of-motion activities are generally encouraged as soon as possible to promote circulation and help prevent lymphedema. Immobilization can actually increase the risk of lymphedema.
B. This intervention is not recommended for preventing lymphedema. Sleeping on the side of the surgery (in this case, the left side) can put pressure on the affected arm and may not promote proper lymphatic drainage. Clients are often advised to sleep on their back or to position themselves in a way that does not compress the affected arm.
C. This intervention can provide temporary relief if there is swelling or discomfort, but it does not effectively prevent lymphedema. While cool compresses might help reduce inflammation, they are not a primary measure for lymphedema prevention.
D. This is the most effective intervention for preventing lymphedema. Elevating the affected arm helps facilitate lymphatic drainage and reduces the risk of fluid accumulation. Keeping the arm elevated above heart level encourages proper circulation and helps manage swelling.
Correct Answer is C
Explanation
A.PSA is primarily associated with prostate health and is not an effective marker for diagnosing other male cancers. While elevated PSA levels can sometimes indicate issues related to the prostate, they are not used for diagnosing other types of cancer.
B. In fact, PSA levels are usually increased in the presence of prostate cancer. While there can be some conditions that lead to a decrease in PSA levels, cancer itself typically raises PSA levels.
C.PSA is commonly used as a screening tool for prostate cancer. Elevated PSA levels may prompt further investigation, including biopsies, to determine if cancer is present. However, it’s important to note that elevated PSA can also occur due to benign conditions like prostatitis or benign prostatic hyperplasia (BPH).
D.While PSA levels can indicate the possibility of prostate cancer, they do not provide a definitive diagnosis. A diagnosis of prostate cancer typically requires further testing, such as a prostate biopsy, to confirm the presence of cancerous cells.
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