STROKESCA
411-STROKE
SCALE
ANSWERS,
LATEST
UPDATED
2022/23
, AttemptKHistory
Hernandez,KDelmy
01KNIHSSEnglishKGroupKAV3K 1stKCertification
Date Result
3/3/2018K4:12:38KAM Passed 89KofK90K (98.89K%) ViewKResponses
PatientK 1
Topic Question Answer Grade
LevelKofKConsc 1a.KLevelKofKConsciousn 0K=KAlert;KkeenlyKresponsive Correct
iousness ess:KTheKinvestigatorKm
ustKchooseKaKresponse,K
evenKifKaKfullKevaluation
KisKpreventedKbyKsuchKo
bstaclesKasKanKendotrac
healKtube,KlanguageKba
rrier,KorotrachealKtraum
a/bandages.KAK3KisKscore
dKonlyKifKtheKpatientKma
kesKnoKmovementK(oth
erKthanKreflexiveKpostur
ing)KinKresponseKtoKnoxi
ousKstimulation.
LOCKQuestions 1b.KLOCKQuestions:KThe 0K=KAnswersKbothKquestions Correct
patientKisKaskedKtheKmo Kcorrectly
nthKandKhis/herKage.KTh
eKanswerKmustKbeKcorre
ctKthereKisKnoKpartialKcr
editKforKbeingKclose.KAp
hasicKandKstuporousKpa
tientsKwhoKdoKnotKcomp
rehendKtheKquestionsKw
illKscoreK2.KPatientsKuna
bleKtoKspeakKbecauseKofK
endotrachealKintubation,
KorotrachealKtrauma,Kse
vereKdysarthriaKfromKan
yKcause,KlanguageKbarri
erKorKanyKotherKproble
mKnotKsecondaryKtoKap
hasiaKareKgivenKaK1.KItKis
KimportantKthatKonlyKth
eKinitialKanswerKbeKgrad
edKandKthatKtheKexamin
erKnotK"help"KtheKpatien
tKwithKverbalKorKnonver
balKcues.
LOCKCommands 1c.K LOCK Commands: 0K=KPerformsKbothKtasksKcorrectlyKCorrect
TheKpatientKisKaskedKto
KopenKandKcloseKtheKeye
sKandKthenKtoKgripKand
, releaseKtheKnonpareticK
hand.KSubstituteKanoth
erKoneKstepKcommandKif
KtheKhandsKcannotKbeKu
sed.KCreditKisKgivenKifKa
nKunequivocalKattemptKi
sKmadeKbutKnotKcomplet
edKdueKtoKweakness.KIfK
theKpatientKdoesKnotKre
spondKtoKcommand,Kth
eKtaskKshouldKbeKdemo
nstratedKtoKthemK(pant
omime)KandKscoreKtheKr
esultK(i.e.,KfollowsKnone
,KoneKorKtwoKcommands
).KPatientsKwithKtrauma
,Kamputation,KorKotherK
physicalKimpedimentsKs
houldKbeKgivenKsuitableK
onestepKcommands.
OnlyKtheKfirstK attemptKis
scored.
BestKGaze
2.KBestKGaze:KOn
lyKhorizontalKeyeKmove 0K=KNormal Correct
mentsKwillKbeKtested.Vo
luntaryKorKreflexiveK(ocu
locephalic)KeyeKmovem
entsKwillKbeKscoredKbutK
caloricKtestingKisKnotKdo
ne.KIfKtheKpatientKhasKa
KconjugateKdeviationKof
KtheKeyesKthatKcanKbeKo
vercomeKbyKvoluntaryK
orKreflexiveKactivity,Kthe
KscoreKwillKbeK1.KIfKaKpa
tientKhasKanKisolatedKpe
ripheralKnerveKparesisK(
CNKIII,KIVKorKVI)KscoreK
aK1.KGazeKisKtestableKin
KallKaphasicKpatients.
PatientsKwithKocular
trauma,Kbandages,Kpre
KexistingKblindnessKorK
otherKdisorderKofKvisual
KacuityKorKfieldsKshould
KbeKtestedKwithKreflexiv
eKmovementsKandKaKc
hoiceKmadeKbyKtheKinv
estigator.
EstablishingKeyeKcontact
KandKthenKmovingKabou
tKtheKpatientKfromKsideK
toKsideKwillKoccasionall
y
, clarifyKtheKpresenceKofKaK
partialKgazeKpalsy.
Visual 0K=KNoKvisualKloss Correct
3.KVisual:KVisualKf
ieldsK(upperKandKlowerK
quadrants)KareKtestedKby
Kconfrontation,KusingKfin
gerKcountingKorKvisualKth
reatKasKappropriate.
PatientKmustKbeKencour
aged,KbutKifKtheyKlookKa
tKtheKsideKofKtheKmovin
gKfingersKappropriately,
KthisKcanKbeKscoredKasK
normal.KIfKthereKisKunila
teralKblindnessK orKenucl
eation,KvisualKfieldsKinKth
eKremainingKeyeKareKsco
red.KScoreK1KonlyKifKaKcle
arcutKasymmetry,Kinclu
dingKquadrantanopiaKisK
found.KIfKpatientKisKblind
KfromKanyKcauseKscoreK3
.KDoubleKsimultaneousK
stimulationKisKperformed
KatKthisKpoint.KIfKthereKi
sKextinctionKpatientKrec
eivesKaK1,KandKtheKresul
tsKareKusedKtoKanswerKq
uestionK11.
FacialKPalsy 0K=KNormalKsymmetrical Correct
4.KFacialKPalsy:KA Kmovement
sk,KorKuseKpantomimeKt
oKencourageKtheKpatientK
toKshowKteethKorKraiseKe
yebrowsKandKcloseKeyes
.KScoreKsymmetryKofKgri
maceKinKresponseKtoKno
xiousKstimuliKinKtheKpoor
lyKresponsiveKorKnonco
mprehendingKpatient.KIf
Kfacial Ktrauma/bandage
s,KorotrachealKtube,Ktap
eKorKotherKphysicalKbarr
iersKobscureKtheKface,Kt
heseKshouldKbeKremove
dKtoKtheKextentKpossible
.
MotorK Arms 5a.KMotorKArmKLeft:KThe 0K=KNoKdrift,KlimbKholdsK90K(or Incorrect
limbKisKplacedKinKtheKap K45)KdegreesKforKfullK10Ksecond
propriateKposition:Kexte s
ndKtheKarmsK(palmsKdo
wn)K90KdegreesK(ifKsitti
ng)KorK45KdegreesK(ifKsu
pine).KDriftKisKscoredKif
411-STROKE
SCALE
ANSWERS,
LATEST
UPDATED
2022/23
, AttemptKHistory
Hernandez,KDelmy
01KNIHSSEnglishKGroupKAV3K 1stKCertification
Date Result
3/3/2018K4:12:38KAM Passed 89KofK90K (98.89K%) ViewKResponses
PatientK 1
Topic Question Answer Grade
LevelKofKConsc 1a.KLevelKofKConsciousn 0K=KAlert;KkeenlyKresponsive Correct
iousness ess:KTheKinvestigatorKm
ustKchooseKaKresponse,K
evenKifKaKfullKevaluation
KisKpreventedKbyKsuchKo
bstaclesKasKanKendotrac
healKtube,KlanguageKba
rrier,KorotrachealKtraum
a/bandages.KAK3KisKscore
dKonlyKifKtheKpatientKma
kesKnoKmovementK(oth
erKthanKreflexiveKpostur
ing)KinKresponseKtoKnoxi
ousKstimulation.
LOCKQuestions 1b.KLOCKQuestions:KThe 0K=KAnswersKbothKquestions Correct
patientKisKaskedKtheKmo Kcorrectly
nthKandKhis/herKage.KTh
eKanswerKmustKbeKcorre
ctKthereKisKnoKpartialKcr
editKforKbeingKclose.KAp
hasicKandKstuporousKpa
tientsKwhoKdoKnotKcomp
rehendKtheKquestionsKw
illKscoreK2.KPatientsKuna
bleKtoKspeakKbecauseKofK
endotrachealKintubation,
KorotrachealKtrauma,Kse
vereKdysarthriaKfromKan
yKcause,KlanguageKbarri
erKorKanyKotherKproble
mKnotKsecondaryKtoKap
hasiaKareKgivenKaK1.KItKis
KimportantKthatKonlyKth
eKinitialKanswerKbeKgrad
edKandKthatKtheKexamin
erKnotK"help"KtheKpatien
tKwithKverbalKorKnonver
balKcues.
LOCKCommands 1c.K LOCK Commands: 0K=KPerformsKbothKtasksKcorrectlyKCorrect
TheKpatientKisKaskedKto
KopenKandKcloseKtheKeye
sKandKthenKtoKgripKand
, releaseKtheKnonpareticK
hand.KSubstituteKanoth
erKoneKstepKcommandKif
KtheKhandsKcannotKbeKu
sed.KCreditKisKgivenKifKa
nKunequivocalKattemptKi
sKmadeKbutKnotKcomplet
edKdueKtoKweakness.KIfK
theKpatientKdoesKnotKre
spondKtoKcommand,Kth
eKtaskKshouldKbeKdemo
nstratedKtoKthemK(pant
omime)KandKscoreKtheKr
esultK(i.e.,KfollowsKnone
,KoneKorKtwoKcommands
).KPatientsKwithKtrauma
,Kamputation,KorKotherK
physicalKimpedimentsKs
houldKbeKgivenKsuitableK
onestepKcommands.
OnlyKtheKfirstK attemptKis
scored.
BestKGaze
2.KBestKGaze:KOn
lyKhorizontalKeyeKmove 0K=KNormal Correct
mentsKwillKbeKtested.Vo
luntaryKorKreflexiveK(ocu
locephalic)KeyeKmovem
entsKwillKbeKscoredKbutK
caloricKtestingKisKnotKdo
ne.KIfKtheKpatientKhasKa
KconjugateKdeviationKof
KtheKeyesKthatKcanKbeKo
vercomeKbyKvoluntaryK
orKreflexiveKactivity,Kthe
KscoreKwillKbeK1.KIfKaKpa
tientKhasKanKisolatedKpe
ripheralKnerveKparesisK(
CNKIII,KIVKorKVI)KscoreK
aK1.KGazeKisKtestableKin
KallKaphasicKpatients.
PatientsKwithKocular
trauma,Kbandages,Kpre
KexistingKblindnessKorK
otherKdisorderKofKvisual
KacuityKorKfieldsKshould
KbeKtestedKwithKreflexiv
eKmovementsKandKaKc
hoiceKmadeKbyKtheKinv
estigator.
EstablishingKeyeKcontact
KandKthenKmovingKabou
tKtheKpatientKfromKsideK
toKsideKwillKoccasionall
y
, clarifyKtheKpresenceKofKaK
partialKgazeKpalsy.
Visual 0K=KNoKvisualKloss Correct
3.KVisual:KVisualKf
ieldsK(upperKandKlowerK
quadrants)KareKtestedKby
Kconfrontation,KusingKfin
gerKcountingKorKvisualKth
reatKasKappropriate.
PatientKmustKbeKencour
aged,KbutKifKtheyKlookKa
tKtheKsideKofKtheKmovin
gKfingersKappropriately,
KthisKcanKbeKscoredKasK
normal.KIfKthereKisKunila
teralKblindnessK orKenucl
eation,KvisualKfieldsKinKth
eKremainingKeyeKareKsco
red.KScoreK1KonlyKifKaKcle
arcutKasymmetry,Kinclu
dingKquadrantanopiaKisK
found.KIfKpatientKisKblind
KfromKanyKcauseKscoreK3
.KDoubleKsimultaneousK
stimulationKisKperformed
KatKthisKpoint.KIfKthereKi
sKextinctionKpatientKrec
eivesKaK1,KandKtheKresul
tsKareKusedKtoKanswerKq
uestionK11.
FacialKPalsy 0K=KNormalKsymmetrical Correct
4.KFacialKPalsy:KA Kmovement
sk,KorKuseKpantomimeKt
oKencourageKtheKpatientK
toKshowKteethKorKraiseKe
yebrowsKandKcloseKeyes
.KScoreKsymmetryKofKgri
maceKinKresponseKtoKno
xiousKstimuliKinKtheKpoor
lyKresponsiveKorKnonco
mprehendingKpatient.KIf
Kfacial Ktrauma/bandage
s,KorotrachealKtube,Ktap
eKorKotherKphysicalKbarr
iersKobscureKtheKface,Kt
heseKshouldKbeKremove
dKtoKtheKextentKpossible
.
MotorK Arms 5a.KMotorKArmKLeft:KThe 0K=KNoKdrift,KlimbKholdsK90K(or Incorrect
limbKisKplacedKinKtheKap K45)KdegreesKforKfullK10Ksecond
propriateKposition:Kexte s
ndKtheKarmsK(palmsKdo
wn)K90KdegreesK(ifKsitti
ng)KorK45KdegreesK(ifKsu
pine).KDriftKisKscoredKif
