A 58-year-old male is admitted with suspected acute stroke. The triage nurse performs an assessment using the Cincinnati Prehospital Stroke Scale (CPSS). Which three physical findings comprise this validated rapid assessment tool?

Answer and explanation

Correct answer: C. Facial droop, arm drift, and abnormal speech

  1. Step 1: The Cincinnati Prehospital Stroke Scale (CPSS) evaluates three key physical parameters: Facial Droop (ask patient to smile/show teeth), Arm Drift (patient holds both arms out with palms up and eyes closed for 10 seconds), and Abnormal Speech (ask patient to repeat a standard phrase).
  2. Step 2: The presence of any one of these three abnormal findings carries a > 72% probability of acute ischemic stroke.
Answer
Facial droop, arm drift, and abnormal speech.
Why not the others: 'Pupillary reflex, handgrip strength...' is a generalized motor exam; 'Blood pressure disparity...' assesses aortic dissection; 'Visual field, gait ataxia...' are components of the expanded NIHSS, not the rapid 3-item Cincinnati scale.

Practise more Primary Nursing, Acute Patient Assessment and Triage.

Free questions with an explanation for every one, and full timed MOH Prometric mock tests.

All Primary Nursing, Acute Patient Assessment and Triage questionsTake a mock test

More Primary Nursing, Acute Patient Assessment and Triage questions