While-interviewing an elderly client, the nurse observes that the client's hands tremble uncontrollably while reaching for a glass of water. How should the nurse document this finding?

Sensory dysfunction.

Transient ischemic attack.

Muscle flaccidity.

Intention tremor.

Answer and Explanation

The Correct Answer is D

A. Sensory dysfunction. Sensory dysfunction refers to impairment or abnormalities in the sensory system, such as touch, proprioception, or temperature sensation. Tremors, particularly those affecting movement, are not typically associated with sensory dysfunction.

B. Transient ischemic attack. Transient ischemic attack (TIA) is a temporary interruption of blood flow to the brain, resulting in transient neurological symptoms. Tremors are not a characteristic symptom of TIA, although other neurological deficits such as weakness, numbness, or speech disturbances may occur.

C. Muscle flaccidity. Muscle flaccidity refers to a state of reduced muscle tone or weakness, often associated with conditions such as stroke or spinal cord injury. Tremors are not typically described as muscle flaccidity; instead, they often involve rhythmic, involuntary movements of the muscles.

D. Intention tremor. This is the most appropriate option. An intention tremor is a type of tremor that occurs during purposeful movement, such as reaching for an object. It is often characterized by tremors that worsen as the individual approaches the target (e.g., reaching for a glass of water). Intention tremors can be associated with various neurological conditions, including essential tremor or cerebellar dysfunction.

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Correct Answer is D

Explanation

A. Mother's use of alcohol, drugs, or cigarettes during pregnancy: While this information might be relevant to the child's medical history, it's not directly related to planning care for the umbilical hernia repair surgery itself.

B. List of achievement timeline for developmental milestones: This information might be helpful for a general paediatric assessment, but it's not crucial for planning care specific to an umbilical hernia repair.

C. A history of rubella, rubeola, or chicken pox: Unless there are complications related to these illnesses, they are not directly relevant to the surgery.

D. Reactions to any previous hospitalizations: This information is vital. Knowing how the child reacted to previous hospitalizations (anaesthesia, medications, separation anxiety) can help the nurse anticipate potential challenges and develop strategies to create a positive experience for the child.

A. Open-ended question. B. Clarification. C. Empathizing. D. Paraphrasing.

Correct Answer is C

Explanation

A. Open-ended question. This response is not an open-ended question. Open-ended questions typically invite the client to share more information or elaborate on their thoughts and feelings. Instead, the nurse's response acknowledges the client's feelings and demonstrates empathy without directly soliciting more information.

B. Clarification. This response is not clarification. Clarification involves seeking clarification or additional information to ensure understanding. The nurse's response does not seek clarification but rather acknowledges the client's emotions.

C. Empathizing. This response is empathizing. Empathizing involves recognizing and understanding the client's emotions and expressing empathy. The nurse's response acknowledges the client's difficult situation and validates their feelings of distress, demonstrating empathy and understanding.

D. Paraphrasing. This response is not paraphrasing. Paraphrasing involves restating the client's message in the nurse's own words to confirm understanding. The nurse's response does not restate the client's message but rather expresses empathy and validation of the client's emotions.

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While-interviewing an elderly client, the nurse observes that the client's hands tremble uncontrollably while reaching for a glass of water. How should the nurse document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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