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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
No explanation
Correct Answer is B
Explanation
A. Determine degree of skin elasticity: While decreased skin elasticity can be a sign of aging, it doesn't directly assess muscle tone or strength.
B. Measure muscle strength: This is the most appropriate next step to confirm the nurse's initial suspicion of weak muscles. Techniques like manual muscle testing can assess muscle strength.
C. Inspect appearance of the spine: Spinal issues can affect movement and coordination, but they wouldn't necessarily explain soft and boggy muscles in one arm.
D. Note 24-hour fluid intake and output: This might be relevant for overall health assessment but doesn't directly assess muscle tone or strength.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.