NRSG 251- STROKE SCALE ANSWERS 2-2022

NRSG 251- STROKE SCALE ANSWERS 2-2022

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 Consciousness 1a. Level of

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.

• = Alert; keenly responsive Correct

LOC Questions 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 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- verb al cues.

• = Answers both

questions correctly

Correct

LOC Commands 1c. LOC Commands:

The patient is asked to open and close the eyes and then to grip and

• = Performs both tasks correctly Correct

release the non-paretic hand. Substitute 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 and then moving about the patient from side to side will occasionally

• = Normal Correct

clarify the presence of a partial gaze palsy.

Visual 3. Visual: Visual fields

(upper and lower quadrants) are tested by confrontation, using finger counting or visual threat as appropriate.Patient must be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-cut asymmetry, including quadrantanopia is found. If patient is blind from any cause score 3.Double simultaneous stimulation is performed at this point. If there is extinction patient receives a 1, and the results are used to answer question 11.

• = No visual loss Correct

Facial Palsy 4. Facial Palsy: Ask, or

use pantomime to encourage the patient to show teeth or raise eyebrows and close eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non-comprehending patient. If facial trauma/bandages, orotracheal tube, tape or other physical barriers obscure the face, these should be removed to the extent possible.

Motor Arms 5a. Motor Arm Left: The

limb is placed in the

appropriate position:

extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if

• = Normal symmetrical

movement

• = No drift, limb holds 90 (or

45) degrees for full 10 seconds Correct

Incorrect