A client who suffered a stroke 6 months ago and participating in a rehab program is able to actively move the both lower legs against gravity and some resistance. How should the nurse document this finding using the muscle strength grading scale?
Explanation & Rationale
A) 2: A muscle strength grade of 2 indicates that the muscle can move when gravity is eliminated, such as when the limb is supported. However, it does not have enough strength to move against gravity. This grade is not appropriate for the client described, as they can move both lower legs against gravity. B) 3: A muscle strength grade of 3 means that the muscle can move the joint against gravity but without any additional resistance. This is less than the client’s described ability, as they can move their legs against some resistance. C) 4: A muscle strength grade of 4 indicates that the muscle can move against gravity and moderate resistance. This matches the client’s ability to actively move both lower legs against gravity and some resistance, making it the correct documentation of their muscle strength. D) 5: A muscle strength grade of 5 indicates normal muscle strength, where the muscle can move against gravity and full resistance without any signs of fatigue. Since the client is described as moving against some resistance but not full resistance, a grade of 5 would overestimate their current muscle strength.