NIH Stroke Scale Exam with
100%questions and answers written
correctly
How to assess Level of Consciousness? - correct answer <<<<<<<<<<<1a.
Deteremine if patient is alert, oriented x4
1b. The patient is asked the 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. It is important
that only the initial answer be graded and that the examiner not "help" the patient with
verbal or non-verbal cue.
1c. The patient is asked to open and close the
eyes and then to grip and release the non-paretic hand. If the patient does not respond
to command, the task
should be demonstrated to him or her (pantomime), and the result scored (i.e., follows
none, one or two commands)
What are the results? - correct answer <<<<<<<<<<<0 = Alert; keenly responsive.
1 = Not alert; but arousable by minor stimulation to obey,
answer, or respond.
2 = Not alert; requires repeated stimulation to attend, or is obtunded and requires
strong or painful stimulation to
make movements (not stereotyped).
3 = Responds only with reflex motor or autonomic effects or totally unresponsive,
flaccid, and areflexic.
0 = Answers both questions correctly.
1 = Answers one question correctly.
2 = Answers neither question correctly
0 = Performs both tasks correctly.
1 = Performs one task correctly.
2 = Performs neither task correctly.
How to assess best gaze? - correct answer <<<<<<<<<<<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 1If a patient has an isolated peripheral
nerve paresis (CN III, IV or VI), score a 1
What are the results? - correct answer <<<<<<<<<<<0 = Normal.
1 = Partial gaze palsy; gaze is abnormal in one or both eyes,
but forced deviation or total gaze paresis is not present.
2 = Forced deviation, or total gaze
How to assess visual gaze? - correct answer <<<<<<<<<<<Visual fields (upper and
lower quadrants) are tested by
confrontation, using finger counting or visual threat, as appropriate.
If there is unilateral blindness or enucleation, visual fields in the remaining eye are
scored.
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 respond to item 11.
What are the results? - correct answer <<<<<<<<<<<0 = No visual loss.
1 = Partial hemianopia.
2 = Complete hemianopia.
3 = Bilateral hemianopia (blind including cortical blindness).
How to assess facial palsy? - correct answer <<<<<<<<<<<Ask - or use pantomime to
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 non-comprehending patient.
What are the results? - correct answer <<<<<<<<<<<0 = Normal symmetrical
movements.
1 = Minor paralysis (flattened nasolabial fold, asymmetry on
smiling).
2 = Partial paralysis (total or near-total paralysis of lower
face).
3 = Complete paralysis of one or both sides (absence of
facial movement in the upper and lower face)
How to assess motor arm and leg? - correct answer <<<<<<<<<<<The limb is placed in
the 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 non-paretic arm.
, What are the results? - correct answer <<<<<<<<<<<0 = No drift; limb holds 90 (or 45)
degrees for full 10 seconds.
1 = Drift; limb holds 90 (or 45) degrees, but drifts down before
full 10 seconds; does not hit bed or other support.
2 = Some effort against gravity; limb cannot get to or
maintain (if cued) 90 (or 45) degrees, drifts down to bed,
but has some effort against gravity.
3 = No effort against gravity; limb falls.
4 = No movement.
UN = Amputation or joint fusion, explain:
Same as 5 - correct answer <<<<<<<<<<<Same as 5
What are the results? - correct answer <<<<<<<<<<<0 = No drift; limb holds 90 (or 45)
degrees for full 10 seconds.
1 = Drift; limb holds 90 (or 45) degrees, but drifts down before
full 10 seconds; does not hit bed or other support.
2 = Some effort against gravity; limb cannot get to or
maintain (if cued) 90 (or 45) degrees, drifts down to bed,
but has some effort against gravity.
3 = No effort against gravity; limb falls.
4 = No movement.
UN = Amputation or joint fusion, explain:
How to assess limb ataxia? - correct answer <<<<<<<<<<<This item is aimed at finding
evidence of a unilateral
cerebellar lesion. Test with eyes open. In case of visual defect, ensure testing is done in
intact visual field. The finger-nose-finger and heel-shin tests are performed on both
sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is
absent in the
patient who cannot understand or is paralyzed.
What are the results? - correct answer <<<<<<<<<<<0 = Absent.
1 = Present in one limb.
2 = Present in two limbs.
UN = Amputation or joint fusion, explain
How to assess sensory? - correct answer <<<<<<<<<<<Sensation or grimace to
pinprick when tested, or
withdrawal from noxious stimulus in the obtunded or aphasic patient.
Only sensory loss attributed to stroke is scored as abnormal and the examiner should
test as many body areas (arms [not hands], legs, trunk, face) as needed to accurately
check for hemisensory loss.
100%questions and answers written
correctly
How to assess Level of Consciousness? - correct answer <<<<<<<<<<<1a.
Deteremine if patient is alert, oriented x4
1b. The patient is asked the 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. It is important
that only the initial answer be graded and that the examiner not "help" the patient with
verbal or non-verbal cue.
1c. The patient is asked to open and close the
eyes and then to grip and release the non-paretic hand. If the patient does not respond
to command, the task
should be demonstrated to him or her (pantomime), and the result scored (i.e., follows
none, one or two commands)
What are the results? - correct answer <<<<<<<<<<<0 = Alert; keenly responsive.
1 = Not alert; but arousable by minor stimulation to obey,
answer, or respond.
2 = Not alert; requires repeated stimulation to attend, or is obtunded and requires
strong or painful stimulation to
make movements (not stereotyped).
3 = Responds only with reflex motor or autonomic effects or totally unresponsive,
flaccid, and areflexic.
0 = Answers both questions correctly.
1 = Answers one question correctly.
2 = Answers neither question correctly
0 = Performs both tasks correctly.
1 = Performs one task correctly.
2 = Performs neither task correctly.
How to assess best gaze? - correct answer <<<<<<<<<<<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 1If a patient has an isolated peripheral
nerve paresis (CN III, IV or VI), score a 1
What are the results? - correct answer <<<<<<<<<<<0 = Normal.
1 = Partial gaze palsy; gaze is abnormal in one or both eyes,
but forced deviation or total gaze paresis is not present.
2 = Forced deviation, or total gaze
How to assess visual gaze? - correct answer <<<<<<<<<<<Visual fields (upper and
lower quadrants) are tested by
confrontation, using finger counting or visual threat, as appropriate.
If there is unilateral blindness or enucleation, visual fields in the remaining eye are
scored.
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 respond to item 11.
What are the results? - correct answer <<<<<<<<<<<0 = No visual loss.
1 = Partial hemianopia.
2 = Complete hemianopia.
3 = Bilateral hemianopia (blind including cortical blindness).
How to assess facial palsy? - correct answer <<<<<<<<<<<Ask - or use pantomime to
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 non-comprehending patient.
What are the results? - correct answer <<<<<<<<<<<0 = Normal symmetrical
movements.
1 = Minor paralysis (flattened nasolabial fold, asymmetry on
smiling).
2 = Partial paralysis (total or near-total paralysis of lower
face).
3 = Complete paralysis of one or both sides (absence of
facial movement in the upper and lower face)
How to assess motor arm and leg? - correct answer <<<<<<<<<<<The limb is placed in
the 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 non-paretic arm.
, What are the results? - correct answer <<<<<<<<<<<0 = No drift; limb holds 90 (or 45)
degrees for full 10 seconds.
1 = Drift; limb holds 90 (or 45) degrees, but drifts down before
full 10 seconds; does not hit bed or other support.
2 = Some effort against gravity; limb cannot get to or
maintain (if cued) 90 (or 45) degrees, drifts down to bed,
but has some effort against gravity.
3 = No effort against gravity; limb falls.
4 = No movement.
UN = Amputation or joint fusion, explain:
Same as 5 - correct answer <<<<<<<<<<<Same as 5
What are the results? - correct answer <<<<<<<<<<<0 = No drift; limb holds 90 (or 45)
degrees for full 10 seconds.
1 = Drift; limb holds 90 (or 45) degrees, but drifts down before
full 10 seconds; does not hit bed or other support.
2 = Some effort against gravity; limb cannot get to or
maintain (if cued) 90 (or 45) degrees, drifts down to bed,
but has some effort against gravity.
3 = No effort against gravity; limb falls.
4 = No movement.
UN = Amputation or joint fusion, explain:
How to assess limb ataxia? - correct answer <<<<<<<<<<<This item is aimed at finding
evidence of a unilateral
cerebellar lesion. Test with eyes open. In case of visual defect, ensure testing is done in
intact visual field. The finger-nose-finger and heel-shin tests are performed on both
sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is
absent in the
patient who cannot understand or is paralyzed.
What are the results? - correct answer <<<<<<<<<<<0 = Absent.
1 = Present in one limb.
2 = Present in two limbs.
UN = Amputation or joint fusion, explain
How to assess sensory? - correct answer <<<<<<<<<<<Sensation or grimace to
pinprick when tested, or
withdrawal from noxious stimulus in the obtunded or aphasic patient.
Only sensory loss attributed to stroke is scored as abnormal and the examiner should
test as many body areas (arms [not hands], legs, trunk, face) as needed to accurately
check for hemisensory loss.
