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 A
Explanation
A. Decreased height: Osteoporosis often leads to vertebral fractures, especially in the upper (thoracic) spine. These fractures can cause pain, height loss, and a stooped or hunched posture (kyphosis).
B. Loss of appetite: While osteoporosis itself does not directly cause loss of appetite, it’s essential to assess overall health and nutritional status. However, this symptom is not directly related to kyphosis.
C. Weight gain: Weight gain is not typically associated with osteoporosis or kyphosis. It is less relevant in this context.
D. Painful swallowing: Painful swallowing is not directly related to osteoporosis or kyphosis. It is less relevant in this context.
Correct Answer is B
Explanation
A. Telling the client the medication needs more time: While true for some medications, it's important to assess the severity of the pain to determine if further action is needed.
B. Reassessing the client's pain: This is the most crucial step. Reassessment helps determine the effectiveness of the medication and identify any potential issues.
C. Asking UAP to offer a backrub: While comfort measures can be helpful, delegation to an UAP should only occur after a nurse assessment and with clear instructions. In this case, pain management is the priority.
D. Encouraging deep breaths: Distraction techniques can be a complementary approach, but reassessing the pain level is the most urgent step.
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