STROKE SCA 411-STROKE SCALE ANSWERS 89 OF 90 2023
UPDATE
Attempt History
Hernandez, Delmy
01- NIHSS-English Group A-V3 - 1st Certification
Date Result
3/3/2018 4:12:38 AM Passed 89 of 90 (98.89 %) View Responses
Patient 1
Topic Question Answer Grade
Level of 1a. Level of 0 = Alert; keenly responsive Correct
Consciousness Consciousness: The
investigator must
choose a response, even
if a full evaluation is
prevented by such
obstacles as an
endotracheal tube,
language barrier,
orotracheal
trauma/bandages. A 3 is
scored only if the
patient makes no
movement (other than
reflexive posturing) in
response to noxious
stimulation.
LOC Questions 1b. LOC Questions: The 0 = Answers both questions Correct
patient is asked the correctly
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
intubation, orotracheal
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.
,STROKE SCA 411-STROKE SCALE ANSWERS 89 OF 90 2023
UPDATE
LOC Commands 1c. LOC Commands: 0 = Performs both tasks correctly Correct
The patient is asked to
open and close the eyes
and then to grip and
,STROKE SCA 411-STROKE SCALE ANSWERS 89 OF 90 2023
UPDATE
release the non-paretic and then moving aboutthe patient
hand. Substitute from side toside will occasionally
another one step
command if the hands
cannot be 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.
Best Gaze 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 in
all aphasic patients.
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
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