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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Pupils equal, round, reacts to light (PERRL) This notation accurately reflects the observed findings.

B. Pupils equal, round, reacts to light, and accommodation (PERLA) While it includes accommodation, there was no specific assessment of accommodation mentioned.

C. Neurological status intact. This is too vague and does not provide specific details about the pupils.

D. Glasgow Coma Scale (GCS) of 15. The GCS score indicates overall neurological function, not specific pupil findings.

A. Ask the client to describe the pain. B. Observe body language and movement. C. Identify effective pain relief measures. D. Provide a numeric pain scale.

Correct Answer is A

Explanation

A. Ask the client to describe the pain: This is the most crucial step. A good pain description can reveal characteristics like intensity, location, duration, and aggravating/relieving factors, all aiding in diagnosis.

B. Observe body language and movement: Nonverbal cues like grimacing, guarding (tensing muscles), or restlessness can indicate pain severity or location.

C. Identify effective pain relief measures: While this might be helpful later, it's not the primary way to assess pain quality initially.

D. Provide a numeric pain scale: Pain scales can be helpful for quantifying pain intensity, but a full description provides richer details.

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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

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