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 B

Explanation

A. Inspect for pedal edema. While pedal edema can be a sign of preeclampsia, obtaining blood pressure is a more immediate and crucial assessment.

B. Obtain a blood pressure. This is the correct next step, as rapid weight gain and nausea/vomiting can be symptoms of preeclampsia, which is often accompanied by hypertension.

C. Listen to foetal heart rate. This is important but secondary to assessing the mother's condition, especially when preeclampsia is suspected.

D. Ask for a 24-hour diet recall. This might be relevant for nutritional assessment but is not the priority when preeclampsia is suspected.

A. Detailed questions about a symptom. B. Open ended questioning. C. Leading questions. D. Closed ended questions.

Correct Answer is B

Explanation

A. Detailed questions about a symptom: This technique is beneficial for gathering specific information about a symptom. However, asking detailed questions right from the start may not allow the client to provide a broad overview of their symptoms and could limit the information shared.

B. Open-ended questioning: Open-ended questions encourage the client to describe their symptoms in their own words, providing a comprehensive and detailed account. This approach is particularly useful in understanding the quality, color, and consistency of the sputum, which are important details in the assessment of pneumonia. This technique allows for a thorough and unbiased description of the sputum, which is crucial for a complete health assessment in the context of bilateral pneumonia.

C. Leading questions: Leading questions suggest a particular answer and can bias the client's response. For example, asking "Is your sputum thick and green?" may lead the client to agree even if their sputum is different, thus providing inaccurate information.

D. Closed-ended questions: Closed-ended questions elicit short, often one-word answers, such as "yes" or "no." While these can be useful for clarifying specific details, they do not provide the comprehensive description needed to assess the sputum thoroughly in the context of pneumonia.

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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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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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