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    HESI RN HEALTH ASSESSMENT PROCTORED EXAM

    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?

    Explanation & Rationale

    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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