Management of CareQuestion 1622 of 2368

A client suddenly loses balance, and their face looks uneven. Using BEFAST, what should the nurse do next?

  1. Repeat the Romberg test in 10 minutes
  2. Perform a cranial nerve exam first
  3. Call for assistance immediately
  4. Document the finding and reassess next shift
Show answer

Correct answer: Call for assistance immediately

The T in BEFAST stands for time. Suspected stroke needs help right away.

Source: Nursing Skills, 2nd edition (Open RN, Chippewa Valley Technical College, 2023), Neurological Assessment: National Institutes of Health Stroke Scale. Licensed under CC BY 4.0.

Practice the topic "Management of Care"

Questions last reviewed: 18 October 2026