STROKESCA v
411-STROKE
v
SCALE v
ANSWERS,
v
LATEST v
UPDATEDv
2022/23 v
, Attempt vHistory
Hernandez, vDelmy
01 vNIHSSEnglish vGroup vAV3 v 1st vCertification
Date Result
3/3/2018 v4:12:38 vAM Passed 89vof v90 v (98.89v%) View vResponses
Patient v 1
Topic Question Answer Grade
Level vof 1a. vLevel vof 0 v= vAlert; vkeenly vresponsive Correct
vConsciousness vConsciousness: vThe
vinvestigator vmust
vchoose va vresponse,
veven vif va vfull vevaluation
vis vprevented vby vsuch
vobstacles vas van
vendotracheal vtube,
vlanguage vbarrier,
vorotracheal
vtrauma/bandages.vA v3 vis
vscored vonly vif vthe
vpatient vmakes vno
vmovement v(other vthan
vreflexive vposturing) vin
vresponse vto vnoxious
vstimulation.
LOC vQuestions 1b. vLOC vQuestions: vThe 0v=vAnswersvbothvquestions Correct
patient vis vasked vthe vcorrectly
vmonth vand vhis/her vage.
vThe vanswer vmust vbe
vcorrect vthere vis vno
vpartial vcredit vfor vbeing
vclose. vAphasic vand
vstuporous vpatients
vwho vdo vnot
vcomprehend vthe
vquestions vwill vscore v2.
vPatients vunablevto vspeak
vbecause vof vendotracheal
vintubation, vorotracheal
vtrauma, vsevere
vdysarthria vfrom vany
vcause, vlanguage vbarrier
vor vany vother vproblem
vnot vsecondary vto
vaphasia vare vgiven va v1.vIt
vis vimportant vthat vonly
vthe vinitial vanswer vbe
vgraded vand vthat vthe
vexaminer vnot v"help" vthe
vpatient vwith vverbal vor
vnonverbal vcues.
LOC vCommands 1c. v LOC v Commands: 0 v= vPerforms v both vtasks v correctly vCorrect
The vpatient vis vasked vto
vopen vand vclose vthe veyes
vand vthen vto vgrip vand
, release vthe vnonparetic
vhand. vSubstitute
vanother vone vstep
vcommand vif vthe vhands
vcannot vbe vused. vCredit
vis vgiven vif van
vunequivocal vattempt vis
vmade vbut vnot vcompleted
vdue vto vweakness. vIf vthe
vpatient vdoes vnot
vrespond vto vcommand,
vthe vtask vshould vbe
vdemonstrated vto vthem
v(pantomime) vand vscore
vthe vresult v(i.e., vfollows
vnone, vone vor vtwo
vcommands). vPatients
vwith vtrauma,
vamputation, vor vother
vphysical vimpediments
vshould vbe vgiven vsuitable
vonestep vcommands.
Only vthe vfirst v attempt vis
scored.
Best vGaze 2. vBest vGaze: vOnly 0v= vNormal Correct
vhorizontal veye
vmovements vwill vbe
vtested.Voluntary vor
vreflexive
v(oculocephalic) veye
vmovements vwill vbe
vscored vbut vcaloric
vtesting vis vnot vdone. vIf
vthe vpatient vhas va
vconjugate vdeviation vof
vthe veyes vthat vcan vbe
vovercome vby vvoluntary
vor vreflexive vactivity, vthe
vscore vwill vbe v1. vIf va
vpatient vhas van visolated
vperipheral vnerve vparesis
v(CN vIII, vIV vor vVI)
vscore va v1. vGaze vis
vtestable vin vall vaphasic
vpatients.
Patients vwith vocular
trauma,vbandages, vpre
vexisting vblindness vor
vother vdisorder vof vvisual
vacuity vor vfields vshould
vbevtested vwithvreflexive
vmovements vand va
vchoice vmade vby vthe
vinvestigator.
Establishing veye vcontact
vand vthen vmoving vabout
vthe vpatient vfrom vside vto
vside vwill voccasionally
, clarifyvthevpresencevofva
vpartial vgaze vpalsy.
Visual 3. vVisual: vVisual vfields 0v= vNo vvisual vloss Correct
v(upper vand vlower
vquadrants) varevtestedvby
vconfrontation, vusing
vfinger vcounting vor vvisual
vthreat vas vappropriate.
Patient vmust vbe
vencouraged, vbut vif
vthey vlook vat vthe vside vof
vthe vmoving vfingers
vappropriately, vthis vcan
vbe vscored vas vnormal. vIf
vthere vis vunilateral
vblindness v or
venucleation, vvisual
vfields vin vthe vremaining
veye vare vscored. vScore v1
vonly vif va vclearcut
vasymmetry, vincluding
vquadrantanopia vis
vfound. vIf vpatient vis vblind
vfrom vany vcause vscore v3.
vDouble vsimultaneous
vstimulation vis
vperformed vat vthis
vpoint. vIf vthere vis
vextinction vpatient
vreceives va v1, vand vthe
vresults vare vused vto
vanswer vquestion v11.
Facial vPalsy 4. vFacial vPalsy: vAsk, vor 0v= vNormal vsymmetrical Correct
vuse vpantomime vto vmovement
vencouragevthe vpatient vto
vshow vteeth vor vraise
veyebrows vand vclose
veyes. vScore vsymmetry
vof vgrimace vin vresponse
vto vnoxious vstimuli vin vthe
vpoorly vresponsive vor
vnoncomprehending
vpatient. vIf vfacial
vtrauma/bandages,
vorotracheal vtube, vtape
vor vother vphysical
vbarriers vobscure vthe
vface, vthese vshould vbe
vremoved vto vthe vextent
vpossible.
Motor v Arms 5a. vMotor vArm vLeft: vThe 0v= vNo vdrift, vlimb vholds v90 v(or Incorrect
limb vis vplaced vin vthe v45) vdegreesvfor vfull v10vseconds
vappropriate vposition:
vextend vthe varms v(palms
vdown) v90 vdegrees v(if
vsitting) vor v45 vdegrees v(if
vsupine). vDrift v is vscored
vif
411-STROKE
v
SCALE v
ANSWERS,
v
LATEST v
UPDATEDv
2022/23 v
, Attempt vHistory
Hernandez, vDelmy
01 vNIHSSEnglish vGroup vAV3 v 1st vCertification
Date Result
3/3/2018 v4:12:38 vAM Passed 89vof v90 v (98.89v%) View vResponses
Patient v 1
Topic Question Answer Grade
Level vof 1a. vLevel vof 0 v= vAlert; vkeenly vresponsive Correct
vConsciousness vConsciousness: vThe
vinvestigator vmust
vchoose va vresponse,
veven vif va vfull vevaluation
vis vprevented vby vsuch
vobstacles vas van
vendotracheal vtube,
vlanguage vbarrier,
vorotracheal
vtrauma/bandages.vA v3 vis
vscored vonly vif vthe
vpatient vmakes vno
vmovement v(other vthan
vreflexive vposturing) vin
vresponse vto vnoxious
vstimulation.
LOC vQuestions 1b. vLOC vQuestions: vThe 0v=vAnswersvbothvquestions Correct
patient vis vasked vthe vcorrectly
vmonth vand vhis/her vage.
vThe vanswer vmust vbe
vcorrect vthere vis vno
vpartial vcredit vfor vbeing
vclose. vAphasic vand
vstuporous vpatients
vwho vdo vnot
vcomprehend vthe
vquestions vwill vscore v2.
vPatients vunablevto vspeak
vbecause vof vendotracheal
vintubation, vorotracheal
vtrauma, vsevere
vdysarthria vfrom vany
vcause, vlanguage vbarrier
vor vany vother vproblem
vnot vsecondary vto
vaphasia vare vgiven va v1.vIt
vis vimportant vthat vonly
vthe vinitial vanswer vbe
vgraded vand vthat vthe
vexaminer vnot v"help" vthe
vpatient vwith vverbal vor
vnonverbal vcues.
LOC vCommands 1c. v LOC v Commands: 0 v= vPerforms v both vtasks v correctly vCorrect
The vpatient vis vasked vto
vopen vand vclose vthe veyes
vand vthen vto vgrip vand
, release vthe vnonparetic
vhand. vSubstitute
vanother vone vstep
vcommand vif vthe vhands
vcannot vbe vused. vCredit
vis vgiven vif van
vunequivocal vattempt vis
vmade vbut vnot vcompleted
vdue vto vweakness. vIf vthe
vpatient vdoes vnot
vrespond vto vcommand,
vthe vtask vshould vbe
vdemonstrated vto vthem
v(pantomime) vand vscore
vthe vresult v(i.e., vfollows
vnone, vone vor vtwo
vcommands). vPatients
vwith vtrauma,
vamputation, vor vother
vphysical vimpediments
vshould vbe vgiven vsuitable
vonestep vcommands.
Only vthe vfirst v attempt vis
scored.
Best vGaze 2. vBest vGaze: vOnly 0v= vNormal Correct
vhorizontal veye
vmovements vwill vbe
vtested.Voluntary vor
vreflexive
v(oculocephalic) veye
vmovements vwill vbe
vscored vbut vcaloric
vtesting vis vnot vdone. vIf
vthe vpatient vhas va
vconjugate vdeviation vof
vthe veyes vthat vcan vbe
vovercome vby vvoluntary
vor vreflexive vactivity, vthe
vscore vwill vbe v1. vIf va
vpatient vhas van visolated
vperipheral vnerve vparesis
v(CN vIII, vIV vor vVI)
vscore va v1. vGaze vis
vtestable vin vall vaphasic
vpatients.
Patients vwith vocular
trauma,vbandages, vpre
vexisting vblindness vor
vother vdisorder vof vvisual
vacuity vor vfields vshould
vbevtested vwithvreflexive
vmovements vand va
vchoice vmade vby vthe
vinvestigator.
Establishing veye vcontact
vand vthen vmoving vabout
vthe vpatient vfrom vside vto
vside vwill voccasionally
, clarifyvthevpresencevofva
vpartial vgaze vpalsy.
Visual 3. vVisual: vVisual vfields 0v= vNo vvisual vloss Correct
v(upper vand vlower
vquadrants) varevtestedvby
vconfrontation, vusing
vfinger vcounting vor vvisual
vthreat vas vappropriate.
Patient vmust vbe
vencouraged, vbut vif
vthey vlook vat vthe vside vof
vthe vmoving vfingers
vappropriately, vthis vcan
vbe vscored vas vnormal. vIf
vthere vis vunilateral
vblindness v or
venucleation, vvisual
vfields vin vthe vremaining
veye vare vscored. vScore v1
vonly vif va vclearcut
vasymmetry, vincluding
vquadrantanopia vis
vfound. vIf vpatient vis vblind
vfrom vany vcause vscore v3.
vDouble vsimultaneous
vstimulation vis
vperformed vat vthis
vpoint. vIf vthere vis
vextinction vpatient
vreceives va v1, vand vthe
vresults vare vused vto
vanswer vquestion v11.
Facial vPalsy 4. vFacial vPalsy: vAsk, vor 0v= vNormal vsymmetrical Correct
vuse vpantomime vto vmovement
vencouragevthe vpatient vto
vshow vteeth vor vraise
veyebrows vand vclose
veyes. vScore vsymmetry
vof vgrimace vin vresponse
vto vnoxious vstimuli vin vthe
vpoorly vresponsive vor
vnoncomprehending
vpatient. vIf vfacial
vtrauma/bandages,
vorotracheal vtube, vtape
vor vother vphysical
vbarriers vobscure vthe
vface, vthese vshould vbe
vremoved vto vthe vextent
vpossible.
Motor v Arms 5a. vMotor vArm vLeft: vThe 0v= vNo vdrift, vlimb vholds v90 v(or Incorrect
limb vis vplaced vin vthe v45) vdegreesvfor vfull v10vseconds
vappropriate vposition:
vextend vthe varms v(palms
vdown) v90 vdegrees v(if
vsitting) vor v45 vdegrees v(if
vsupine). vDrift v is vscored
vif
