STROKE SCA 411-STROKE SCALE ANSWERS/STROKE SCA 411-STROKE SCALE ANSWERS. Topic Question Answer Grade Level of Consciousness 1a. Level of Consciousness: The investigator must choose a response, even if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, orotra...
Hernandez, Delmy .
01 NIHSSEnglish Group AV3 1st Certification
Date Result
3/3/2018 4:12:38 AM Passed 89 of 90 (98.89 %) View Responses
Patient 1
Topic Question Answer Grade
Level of 1a. Level of 0 = Alert; keenly responsive Correct
Consciousness Consciousness: The
investigator must
choose a response, even
if a full evaluation is
prevented by such
obstacles as an
endotracheal tube,
language barrier,
orotracheal
trauma/bandages. A 3 is
scored only if the
patient makes no
movement (other than
reflexive posturing) in
response to noxious
stimulation.
LOC Questions 1b. LOC Questions: The 0 = Answers both questions Correct
patient is asked the correctly
month and his/her age.
The answer must be
correct there is no
partial credit for being
close. Aphasic and
stuporous patients who
do not comprehend the
questions will score 2.
Patients unable to speak
because of endotracheal
intubation, orotracheal
trauma, severe
dysarthria from any
cause, language barrier
or any other problem
not secondary to
aphasia are given a 1. It
is important that only
the initial answer be
graded and that the
examiner not "help" the
patient with verbal or
nonverbal cues.
LOC Commands 1c. LOC Commands: 0 = Performs both tasks correctly Correct
The patient is asked to
open and close the eyes
and then to grip and
, release the nonparetic
hand. Substitute
another one step
command if the hands
cannot be used. Credit
is given if an
unequivocal attempt is
made but not completed
due to weakness. If the
patient does not
respond to command,
the task should be
demonstrated to them
(pantomime) and score
the result (i.e., follows
none, one or two
commands). Patients
with trauma,
amputation, or other
physical impediments
should be given suitable
onestep commands.
Only the first attempt is
scored.
Best Gaze 2. Best Gaze: Only 0 = Normal Correct
horizontal eye
movements will be
tested.Voluntary or
reflexive (oculocephalic)
eye movements will be
scored but caloric
testing is not done. If
the patient has a
conjugate deviation of
the eyes that can be
overcome by voluntary
or reflexive activity, the
score will be 1. If a
patient has an isolated
peripheral nerve paresis
(CN III, IV or VI) score
a 1. Gaze is testable in
all aphasic patients.
Patients with ocular
trauma, bandages, pre
existing blindness or
other disorder of visual
acuity or fields should
be tested with reflexive
movements and a
choice made by the
investigator.
Establishing eye contact
and then moving about
the patient from side to
side will occasionally
, clarify the presence of a
partial gaze palsy.
Visual 3. Visual: Visual fields 0 = No visual loss Correct
(upper and lower
quadrants) are tested by
confrontation, using
finger counting or visual
threat as appropriate.
Patient must be
encouraged, but if they
look at the side of the
moving fingers
appropriately, this can
be scored as normal. If
there is unilateral
blindness or
enucleation, visual fields
in the remaining eye are
scored. Score 1 only if a
clearcut asymmetry,
including
quadrantanopia is
found. If patient is blind
from any cause score 3.
Double simultaneous
stimulation is performed
at this point. If there is
extinction patient
receives a 1, and the
results are used to
answer question 11.
Facial Palsy 4. Facial Palsy: Ask, or 0 = Normal symmetrical Correct
use pantomime to movement
encourage the patient to
show teeth or raise
eyebrows and close
eyes. Score symmetry
of grimace in response
to noxious stimuli in the
poorly responsive or
noncomprehending
patient. If facial
trauma/bandages,
orotracheal tube, tape
or other physical
barriers obscure the
face, these should be
removed to the extent
possible.
Motor Arms 5a. Motor Arm Left: The 0 = No drift, limb holds 90 (or Incorrect
limb is placed in the 45) degrees for full 10 seconds
appropriate position:
extend the arms (palms
down) 90 degrees (if
sitting) or 45 degrees (if
supine). Drift is scored if
, the arm falls before 10
seconds. The aphasic
patient is encouraged
using urgency in the
voice and pantomime,
but not noxious
stimulation. Each limb is
tested in turn, beginning
with the nonparetic
arm. Only in the case of
amputation or joint
fusion at the shoulder,
the examiner should
record the score as
untestable (UN)
Motor Arms 5b. Motor Arm Right: 0 = No drift, limb holds 90 (or Correct
Limb is placed in the 45) degrees for full 10 seconds
appropriate position:
extend the arms (palms
down) 90 degrees (if
sitting) or 45 degrees (if
supine). Drift is scored if
the arm falls before 10
seconds. The aphasic
patient is encouraged
using urgency in the
voice and pantomime,
but not noxious
stimulation. Each limb is
tested in turn, beginning
with the nonparetic
arm. Only in the case of
amputation or joint
fusion at the shoulder,
the examiner should
record the score as
untestable (UN)
Motor Legs 6a. Left Leg: The limb is 1 = Drift, leg falls by the end of Correct
placed in the the 5 second period, but does not
appropriate position: hit bed
hold the leg at 30
degrees (always tested
supine). Drift is scored if
the leg falls before 5
seconds. The aphasic
patient is encouraged
using urgency in the
voice and pantomime
but not noxious
stimulation. Each limb is
tested in turn, beginning
with the nonparetic leg.
Only in the case of
amputation or joint
fusion at the hip, the
examiner should record
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