NURS NIH STROKE SCALE EXAM 1

NURS NIH STROKE
SCALE EXAM 1
Score for large strokes - ANSWER>>>> 10



(however, if it is a brainstem stroke it can have a low score and still be a large stroke)

Lowest score



Highest score - ANSWER>>>Lowest score is 0



Highest score is 42

Components of *Eyes* - ANSWER>>>Gaze

- voluntary gaze direction (non-comatose)

- vestibule-ocular reflex (comatose)



Visual fields

- confrontation, all 4 quadrants (non-comatose)

- threat (comatose)

Components of *LOC* - ANSWER>>>Arousal



Questions

- name

- month



Commands

, - open eyes

- grip/release

Components of *Face* - ANSWER>>>Facial droop

- smile & eyebrow raise (normal LOC / drowsy)

- grimace w/ pain (obtunded)

Components of *Motor Strength* - ANSWER>>>Arm strength

- raise arms 45° (supine)

- raise arms 90° (sitting)



Leg strength

- raise legs 30° (always test supine)

Components of *Limb Ataxia* - ANSWER>>>Finger→nose & Heel→shin

Components of *Sensory* - ANSWER>>>Pinprick

- all 4 limbs; up to elbow

Components of *Language* - ANSWER>>>Aphasia

- describe picture; name objects (w/ adequate vision)

- describe large objects in room or ask questions (w/ inadequate vision)

Components of *Dysarthria* - ANSWER>>>Character of speech

- read sentences / words (w/ adequate vision)

- repeat "methodist episcopal" (w/ inadequate vision)

- listen for slurred, garbled, incoherent

Components of *Extinction/Inattention* - ANSWER>>>Vision extinction:

- look at wiggling hand



Sensory test

- upper & lower extensors

Special Cases - ANSWER>>>Unconscious patients will have a high score; does *NOT* mean they had a
stroke