The nurse is assessing the client's muscle strength and notes that when asked, the client cannot maintain his or her hands in a supinated position with the arms extended and eyes closed

Question

How would the nurse correctly document this finding on the medical record? 1. Client is demonstrating ataxia.
2. Client is exhibiting pronator drift.
3. Client examination reveals hyperreflexia.
4. Client appears to have nystagmus.

Answer 1

2

Rationale: Pronator drift occurs when a client cannot maintain his or her hands in a supinated position with the arms extended and eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Ataxia is a disturbance in gait. Hyperreflexia is an excessive reflex action. Nystagmus is characterized by fine, involuntary eye movements. It can occur with neurological disease or as a side effect of selected medications.