When assessing a patient for possible stroke symptoms using the BE FAST acronym, what does the letter “F” represent, and why is it important?
Fatigue – a common sign of neurological decline.
Fever – checking for elevated temperature.
Feet – assessing balance and walking ability.
Face – observing facial drooping/facial asymmetry.
The Correct Answer is D
Choice A reason: Fatigue is not part of BE FAST (Balance, Eyes, Face, Arms, Speech, Time) and is nonspecific, not a primary stroke sign. Facial drooping is critical. Assuming fatigue risks missing urgent stroke symptoms, delaying thrombolytic therapy, essential for minimizing brain damage within the critical time window.
Choice B reason: Fever is not in BE FAST and is not a primary stroke indicator, though it may occur later. Facial asymmetry is a key sign. Assuming fever misdirects assessment, risking delayed stroke recognition, critical for initiating rapid interventions like tPA to restore cerebral perfusion and reduce disability.
Choice C reason: Feet (balance) aligns with “B” in BE FAST, not “F,” which represents facial drooping. Misidentifying this risks confusing stroke assessment, potentially delaying recognition of facial asymmetry, a hallmark sign, critical for prompt stroke intervention to minimize neurological damage and improve patient outcomes.
Choice D reason: In BE FAST, “F” stands for face, assessing facial drooping or asymmetry, a common stroke sign due to cranial nerve VII involvement. It’s critical for rapid identification, enabling timely interventions like thrombolytics within 4.5 hours, minimizing brain damage and improving recovery chances in acute ischemic stroke patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Full thickness skin loss with visible bone indicates a stage 4 pressure injury, not stage 1, which involves intact skin with erythema. Misidentifying this overstates severity, risking inappropriate interventions like surgical debridement instead of preventive measures like repositioning, critical for managing early-stage pressure injuries to prevent progression.
Choice B reason: Stage 1 pressure injury presents as intact skin with non-blanchable localized erythema, often over bony prominences, due to early tissue compression. This finding guides preventive care, like pressure relief and skin protection, to halt progression. Accurate identification ensures timely interventions, reducing risk of deeper tissue damage in at-risk patients.
Choice C reason: Full thickness skin loss with visible adipose tissue describes a stage 3 pressure injury, not stage 1, which has intact skin. Assuming this misdiagnoses severity, leading to unnecessary aggressive treatments like wound dressings, while neglecting early interventions like offloading pressure, critical for preventing worsening of stage 1 injuries.
Choice D reason: Partial-thickness skin loss with red tissue indicates a stage 2 pressure injury, not stage 1, which shows intact skin with erythema. Misidentifying this risks inappropriate wound care, delaying preventive strategies like skin moisturizing or repositioning, essential for managing stage 1 injuries and preventing progression to deeper ulcers.
Correct Answer is C
Explanation
Choice A reason: Normal blood pressure is <120/<80 mmHg, far below 148/92 mmHg, which is stage 2 hypertension per AHA guidelines. Assuming normal misclassifies the reading, risking untreated hypertension, leading to complications like stroke or heart failure. Accurate classification ensures proper management with lifestyle changes or medications.
Choice B reason: Stage 1 hypertension is 130-139/80-89 mmHg, lower than 148/92 mmHg, which is stage 2. Misclassifying as stage 1 underestimates severity, potentially delaying aggressive treatment like dual antihypertensives. Correct staging ensures timely intervention, critical for preventing cardiovascular damage in patients with elevated blood pressure readings.
Choice C reason: Stage 2 hypertension, per AHA, is ≥140/≥90 mmHg, matching 148/92 mmHg. This requires immediate lifestyle changes and likely medications to prevent cardiovascular events. Accurate classification guides treatment, ensuring blood pressure control, reducing risks of stroke, heart attack, or kidney damage in patients with significant hypertension.
Choice D reason: Elevated blood pressure is 120-129/<80 mmHg, below 148/92 mmHg, which is stage 2 hypertension. Assuming elevated underestimates the condition, risking inadequate intervention and progression to organ damage. Correct classification ensures appropriate management, critical for controlling hypertension and preventing long-term complications in affected patients.
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