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    Hesi rn med surg( adult health) proctored exam ICHS college

    While interviewing an older adult 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

    Choice A reason: Intention tremor is the correct documentation because it describes tremors that occur during purposeful movement, such as reaching for a glass of water. This type of tremor is commonly associated with cerebellar dysfunction and is distinct from resting tremors seen in conditions like Parkinson’s disease. Choice B reason: Sensory dysfunction refers to impaired sensation, such as numbness or tingling, not involuntary muscle movements. Tremors are motor abnormalities, so this documentation would be inaccurate. Choice C reason: Muscle flaccidity describes decreased muscle tone or weakness, not involuntary shaking. Flaccidity may occur after neurological injury but does not explain uncontrollable tremors during movement. Choice D reason: Transient ischemic attack (TIA) involves temporary neurological deficits such as weakness, vision changes, or speech disturbances. Tremors are not a typical manifestation of TIA, so this would be an incorrect documentation.

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