NIHSS STROKE SCALE exam practice questions with correct answers

common signs of a stroke •Confusion •Slurred speech •Facial droop •Extremity weakness and/or numbness •Vision disturbance •Dysphasia •Ataxia FAST •FAST - rapid identification for lay people •Does not identify sensory impairment, vertigo or gait changes -Facial droop -Arm weakness -Slurred speech -Time ways to assess a stroke •FAST - rapid identification for lay people •CPSS, LAPSS, ROSIER - used for prehospital and ER recognition •NIHSS NIHSS (National Institutes of Health Stroke Scale) •Reliable and valid •Used to objectively quantify the stroke impairments •Also used in emergent situations to determine treatment planning (the need for tPA) in the 3 - 4.5 hour window, along with clinical decision making •Predictor of short and long-term outcomes •Does not capture all stroke symptoms - vertebrobasilar stroke can cause vertigo, nausea and vomiting, headache, oculomotor signs 1. Level of Consciousness 2. Best Gaze 3. Visual Fields 4. Facial Paresis 5. Motor Arm 6. Motor Leg 7. Limb Ataxia 8. Sensory 9. Best Language 10. Speech 11. Extinction and Inattention 1-11 of the NIHSS 1. Level of Consciousness Divided into 3 sections: •Responsiveness •Questions •Commands 0 = alert; responsive 1 = not alert; arousable by verbal or minor stimuli to respond 2 = not alert; arousable by repeated or strong or painful stimuli to respond; obtunded 3 = unresponsive; only reflexive motor or autonomic movement; unresponsive, flaccid 1a. LOC Responsiveness (scaled 0-3) •Ask what the month is •Ask what the patient age is (not birth year!) ◦0 = both correct ◦1 = one wrong ◦2 = two wrong •NO PARTIAL CREDIT - patient is either right or wrong. Only accept the first answer, make sure no one is helping •Patients unable to speak can write the answer •If they are unresponsive, stuporous and unable to understand the questions or aphasic - score 2 •If they can't talk due to trauma, dysarthria, language barrier, or intubation - score 1 1b. LOC Questions (scaled 0-2) •Ask the patient to open and close eyes, then grip and release hands •May alter the commands if needed •May mime the action if the patient doesn't respond •Attempt is considered successful if attempted but incomplete due to weakness 0 = correctly performs both tasks 1 = correctly performs one task 2 = does not correctly perform either task 1c. LOC Commands (scaled 0-2)