A nurse is caring for a 73-year-old male client in an assisted living facility. The client has a history of a left-sided stroke and is experiencing increasing weakness and a decrease in range of motion (ROM) on the right side. The nurse begins the assessment at 0700hrs.

Exhibits

Based on the exhibits provided, what type of range of motion was being assessed for each joint? Select one response per row.

Choice A rationale
A minor variation may refer to a benign finding or a slight deviation from the norm. However, a low-pitched blowing sound in the upper midline area would not typically be considered a minor variation and may warrant further investigation.
Choice B rationale
Borborygmi are normal bowel sounds characterized by gurgling, rumbling, or growling noises produced by the movement of gas and fluid in the intestines. However, a low-pitched blowing sound in the upper midline area would not typically be described as normal borborygmi.
Choice C rationale
A low-pitched blowing sound in the upper midline area could indicate a renal artery bruit, which is a sign of renal artery stenosis. Renal artery stenosis is a narrowing of the renal artery, often due to atherosclerosis, which can lead to decreased blood flow to the kidneys. A renal artery bruit may be auscultated over the renal arteries and is indicative of turbulent blood flow through the narrowed artery.
Choice D rationale
Hyperactive bowel sounds are typically characterized by loud, high-pitched gurgles heard throughout the abdomen. They are often associated with increased intestinal motility, such as in gastroenteritis or diarrhea, rather than a low-pitched blowing sound in the upper midline area.

Choice A rationale
Sorting a collection of socks may assess cognitive function and fine motor skills, but it does not directly evaluate the ability to perform activities of daily living (ADL) such as bathing, dressing, or feeding.
Choice B rationale
Opening a bar soap package is a practical task that requires fine motor skills and dexterity, which are essential for performing activities of daily living (ADL) such as bathing and grooming.
Choice C rationale
Telephoning a family member assesses communication skills and cognitive function but does not directly evaluate the ability to perform activities of daily living (ADL)3.
Choice D rationale
Reading a short paragraph assesses cognitive function and literacy skills but does not directly evaluate the ability to perform activities of daily living (ADL)3.