STROKE SCA 411 – STROKE SCALE STUDY
GUIDE100% Correct| Verified | Latest Update
COMPLETE 2023
,STROKE SCA 411 – STROKE SCALE STUDY
GUIDE100% Correct| Verified | Latest Update
COMPLETE 2023
Patient 1
Topic Question Answer Grade
1a. Level of
Consciousness: The
investigator must choose a
response, even if a full
evaluation is prevented by
such obstacles as an
endotracheal tube,
Level of
language barrier, 0 = Alert; keenly responsive Correct
Consciousness
orotracheal
trauma/bandages. A 3 is
scored only if the patient
makes no movement (other
than reflexive posturing) in
response to noxious
stimulation.
1b. LOC Questions: 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.
Patients unable to speak
because of endotracheal 0 = Answers both questions
LOC Questions Correct
intubation, orotracheal correctly
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 patient with
verbal or non-verbal cues.
LOC Commands 1c. LOC Commands: The 0 = Performs both tasks Correct
patient is asked to open and correctly
close the eyes and then to
grip and release the non-
,STROKE SCA 411 – STROKE SCALE STUDY
GUIDE100% Correct| Verified | Latest Update
COMPLETE 2023
paretic hand. Substitute
another one step command
if the hands cannot be
, STROKE SCA 411 – STROKE SCALE STUDY
GUIDE100% Correct| Verified | Latest Update
COMPLETE 2023
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
one-step commands. Only
the first attempt is scored.
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
Best Gaze in all aphasic patients. 0 = Normal Correct
Patients with ocular
trauma, bandages, pre-
existing blindness or other
disorder of visual acuity or
fields should be tested with
reflexive movements and a
choice made by the
investigator. Establishing
eye contact and then
moving about the patient
from side to side will
occasionally clarify the
presence of a partial gaze
palsy.
GUIDE100% Correct| Verified | Latest Update
COMPLETE 2023
,STROKE SCA 411 – STROKE SCALE STUDY
GUIDE100% Correct| Verified | Latest Update
COMPLETE 2023
Patient 1
Topic Question Answer Grade
1a. Level of
Consciousness: The
investigator must choose a
response, even if a full
evaluation is prevented by
such obstacles as an
endotracheal tube,
Level of
language barrier, 0 = Alert; keenly responsive Correct
Consciousness
orotracheal
trauma/bandages. A 3 is
scored only if the patient
makes no movement (other
than reflexive posturing) in
response to noxious
stimulation.
1b. LOC Questions: 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.
Patients unable to speak
because of endotracheal 0 = Answers both questions
LOC Questions Correct
intubation, orotracheal correctly
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 patient with
verbal or non-verbal cues.
LOC Commands 1c. LOC Commands: The 0 = Performs both tasks Correct
patient is asked to open and correctly
close the eyes and then to
grip and release the non-
,STROKE SCA 411 – STROKE SCALE STUDY
GUIDE100% Correct| Verified | Latest Update
COMPLETE 2023
paretic hand. Substitute
another one step command
if the hands cannot be
, STROKE SCA 411 – STROKE SCALE STUDY
GUIDE100% Correct| Verified | Latest Update
COMPLETE 2023
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
one-step commands. Only
the first attempt is scored.
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
Best Gaze in all aphasic patients. 0 = Normal Correct
Patients with ocular
trauma, bandages, pre-
existing blindness or other
disorder of visual acuity or
fields should be tested with
reflexive movements and a
choice made by the
investigator. Establishing
eye contact and then
moving about the patient
from side to side will
occasionally clarify the
presence of a partial gaze
palsy.
