NIHSS STROKE SCALE || All Answers are Valid.
common signs of a stroke correct answers •Confusion
•Slurred speech
•Facial droop
•Extremity weakness and/or numbness
•Vision disturbance
•Dysphasia
•Ataxia
FAST correct answers •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 correct answers •FAST - rapid identification for lay people
•CPSS, LAPSS, ROSIER - used for prehospital and ER recognition
•NIHSS
NIHSS (National Institutes of Health Stroke Scale) correct answers •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 correct answers 1-11 of the NIHSS
1. Level of Consciousness correct answers 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 correct
answers 1a. LOC Responsiveness (scaled 0-3)
•Ask what the month is
•Ask what the patient age is (not birth year!)
◦0 = both correct
common signs of a stroke correct answers •Confusion
•Slurred speech
•Facial droop
•Extremity weakness and/or numbness
•Vision disturbance
•Dysphasia
•Ataxia
FAST correct answers •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 correct answers •FAST - rapid identification for lay people
•CPSS, LAPSS, ROSIER - used for prehospital and ER recognition
•NIHSS
NIHSS (National Institutes of Health Stroke Scale) correct answers •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 correct answers 1-11 of the NIHSS
1. Level of Consciousness correct answers 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 correct
answers 1a. LOC Responsiveness (scaled 0-3)
•Ask what the month is
•Ask what the patient age is (not birth year!)
◦0 = both correct
