The nurse applies resistance to the top of the client's foot and asks him to pull his toes toward his knee. The nurse observes active motion against some, but not against full, resistance. How should the nurse document this finding?
a. 5: Normal
b. 4: Slight weakness
c. 3: Weakness
d. 2: Poor ROM
B
The nurse should document 4: Slight weakness. The following is the muscle strength rating scale:
Rating Criteria Classification
5 Active motion against full resistance Normal
4 Active motion against some resistance Slight weakness
3 Active motion against gravity Weakness
2 Passive ROM Poor ROM
1 Slight flicker of contraction Severe weakness
0 No muscular contraction Paralysis
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