NIHSS STROKE SCALE QUESTIONS WITH CORRECT
ANSWERS UPDATED 2025
commonRsignsRofRaRstrokeR-RcorrectRanswer-•Confusion
•SlurredRspeech
•FacialRdroop
•ExtremityRweaknessRand/orRnumbness
•VisionRdisturbance
•Dysphasia
•Ataxia
FASTR-RcorrectRanswer-•FASTR-RrapidRidentificationRforRlayRpeople
•DoesRnotRidentifyRsensoryRimpairment,RvertigoRorRgaitRchanges
-FacialRdroop
-ArmRweakness
-SlurredRspeech
-Time
waysRtoRassessRaRstrokeR-RcorrectRanswer-•FASTR-RrapidRidentificationRforRlayRpeople
•CPSS,RLAPSS,RROSIERR-RusedRforRprehospitalRandRERRrecognition
•NIHSS
NIHSSR(NationalRInstitutesRofRHealthRStrokeRScale)R-RcorrectRanswer-•ReliableRandRvalid
•UsedRtoRobjectivelyRquantifyRtheRstrokeRimpairments
•AlsoRusedRinRemergentRsituationsRtoRdetermineRtreatmentRplanningR(theRneedRforRtPA)RinRtheR3R-
R4.5RhourRwindow,RalongRwithRclinicalRdecisionRmaking
•PredictorRofRshortRandRlong-termRoutcomes
•DoesRnotRcaptureRallRstrokeRsymptomsR-
RvertebrobasilarRstrokeRcanRcauseRvertigo,RnauseaRandRvomiting,Rheadache,RoculomotorRsigns
, 1.RLevelRofRConsciousness
2.RBestRGaze
3.RVisualRFields
4.RFacialRParesis
5.RMotorRArm
6.RMotorRLeg
7.RLimbRAtaxia
8.RSensory
9.RBestRLanguage
10.RSpeech
11.RExtinctionRandRInattentionR-RcorrectRanswer-1-11RofRtheRNIHSS
1.RLevelRofRConsciousnessR-RcorrectRanswer-DividedRintoR3Rsections:
•Responsiveness
•Questions
•Commands
0R=Ralert;Rresponsive
1R=RnotRalert;RarousableRbyRverbalRorRminorRstimuliRtoRrespond
2R=RnotRalert;RarousableRbyRrepeatedRorRstrongRorRpainfulRstimuliRtoRrespond;Robtunded
3R=Runresponsive;RonlyRreflexiveRmotorRorRautonomicRmovement;Runresponsive,RflaccidR-RcorrectRanswer-
1a.RLOCRResponsivenessR(scaledR0-3)
•AskRwhatRtheRmonthRis
•AskRwhatRtheRpatientRageRisR(notRbirthRyear!)
◦0R=RbothRcorrect
◦1R=RoneRwrong
◦2R=RtwoRwrong
•NORPARTIALRCREDITR-
RpatientRisReitherRrightRorRwrong.ROnlyRacceptRtheRfirstRanswer,RmakeRsureRnoRoneRisRhelping
•PatientsRunableRtoRspeakRcanRwriteRtheRanswer
ANSWERS UPDATED 2025
commonRsignsRofRaRstrokeR-RcorrectRanswer-•Confusion
•SlurredRspeech
•FacialRdroop
•ExtremityRweaknessRand/orRnumbness
•VisionRdisturbance
•Dysphasia
•Ataxia
FASTR-RcorrectRanswer-•FASTR-RrapidRidentificationRforRlayRpeople
•DoesRnotRidentifyRsensoryRimpairment,RvertigoRorRgaitRchanges
-FacialRdroop
-ArmRweakness
-SlurredRspeech
-Time
waysRtoRassessRaRstrokeR-RcorrectRanswer-•FASTR-RrapidRidentificationRforRlayRpeople
•CPSS,RLAPSS,RROSIERR-RusedRforRprehospitalRandRERRrecognition
•NIHSS
NIHSSR(NationalRInstitutesRofRHealthRStrokeRScale)R-RcorrectRanswer-•ReliableRandRvalid
•UsedRtoRobjectivelyRquantifyRtheRstrokeRimpairments
•AlsoRusedRinRemergentRsituationsRtoRdetermineRtreatmentRplanningR(theRneedRforRtPA)RinRtheR3R-
R4.5RhourRwindow,RalongRwithRclinicalRdecisionRmaking
•PredictorRofRshortRandRlong-termRoutcomes
•DoesRnotRcaptureRallRstrokeRsymptomsR-
RvertebrobasilarRstrokeRcanRcauseRvertigo,RnauseaRandRvomiting,Rheadache,RoculomotorRsigns
, 1.RLevelRofRConsciousness
2.RBestRGaze
3.RVisualRFields
4.RFacialRParesis
5.RMotorRArm
6.RMotorRLeg
7.RLimbRAtaxia
8.RSensory
9.RBestRLanguage
10.RSpeech
11.RExtinctionRandRInattentionR-RcorrectRanswer-1-11RofRtheRNIHSS
1.RLevelRofRConsciousnessR-RcorrectRanswer-DividedRintoR3Rsections:
•Responsiveness
•Questions
•Commands
0R=Ralert;Rresponsive
1R=RnotRalert;RarousableRbyRverbalRorRminorRstimuliRtoRrespond
2R=RnotRalert;RarousableRbyRrepeatedRorRstrongRorRpainfulRstimuliRtoRrespond;Robtunded
3R=Runresponsive;RonlyRreflexiveRmotorRorRautonomicRmovement;Runresponsive,RflaccidR-RcorrectRanswer-
1a.RLOCRResponsivenessR(scaledR0-3)
•AskRwhatRtheRmonthRis
•AskRwhatRtheRpatientRageRisR(notRbirthRyear!)
◦0R=RbothRcorrect
◦1R=RoneRwrong
◦2R=RtwoRwrong
•NORPARTIALRCREDITR-
RpatientRisReitherRrightRorRwrong.ROnlyRacceptRtheRfirstRanswer,RmakeRsureRnoRoneRisRhelping
•PatientsRunableRtoRspeakRcanRwriteRtheRanswer