https://www.stuvia.com/user/papersprime
STROKE SCA
411-STROKE
SCALE
ANSWERS,
LATEST
UPDATED
2022/23
https://www.stuvia.com/user/papersprime
,https://www.stuvia.com/user/papersprime
Attempt History
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 patie 0 = Answers both questions
patient is asked the nt correctly
month and his/her age. with
The answer must be verba
correct there is no l or
partial credit for being nonv
close. Aphasic and erbal
stuporous patients who cues.
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
https://www.stuvia.com/user/papersprime
,https://www.stuvia.com/user/papersprime
Correct
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
https://www.stuvia.com/user/papersprime
, https://www.stuvia.com/user/papersprime
movements and a choice made by the
release the nonparetic
investigator.
hand. Substitute
Establishing eye contact and then moving
another one step
about the patient from side to side will
command if the hands
occasionally
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
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
https://www.stuvia.com/user/papersprime
STROKE SCA
411-STROKE
SCALE
ANSWERS,
LATEST
UPDATED
2022/23
https://www.stuvia.com/user/papersprime
,https://www.stuvia.com/user/papersprime
Attempt History
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 patie 0 = Answers both questions
patient is asked the nt correctly
month and his/her age. with
The answer must be verba
correct there is no l or
partial credit for being nonv
close. Aphasic and erbal
stuporous patients who cues.
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
https://www.stuvia.com/user/papersprime
,https://www.stuvia.com/user/papersprime
Correct
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
https://www.stuvia.com/user/papersprime
, https://www.stuvia.com/user/papersprime
movements and a choice made by the
release the nonparetic
investigator.
hand. Substitute
Establishing eye contact and then moving
another one step
about the patient from side to side will
command if the hands
occasionally
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
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
https://www.stuvia.com/user/papersprime
