When documenting a musculoskeletal assessment, which of the following descriptions correctly indicates a muscle strength rating of 4/5?

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.

Choice A reason: Urinary retention, the inability to void, is caused by bladder or prostate issues, not dietary fiber intake. Fiber affects gastrointestinal motility, not urinary function. High-fiber diets promote bowel regularity but have no direct impact on bladder emptying, making this choice incorrect.

Choice B reason: High-fiber diets prevent constipation by adding bulk to stool and promoting peristalsis, facilitating regular bowel movements. Fiber absorbs water, softening stool and reducing straining, which is critical for patients with poor nutrition, like Mr. Green, making this the correct choice for dietary intervention.

Choice C reason: Stress incontinence, urine leakage during physical stress, results from weakened pelvic muscles or sphincter dysfunction, not dietary factors. Fiber influences bowel health, not bladder control, so this choice is unrelated to the preventive benefits of a high-fiber diet in gastrointestinal function.

Choice D reason: Hiatal hernia, where the stomach protrudes through the diaphragm, is linked to anatomical or pressure factors, not fiber intake. Fiber supports bowel regularity but does not address esophageal or diaphragmatic issues, making this choice irrelevant to the benefits of high-fiber diets.