NIHSS Certification and Post Test Exam Study Questions with 100% Correct Answers

NIHSS Certification and Post Test Exam Study Questions with 100% Correct Answers 1. A nurse educator is teaching a group of nursing students about use of the NIHSS. The nurse educator is correct to tell the students that the NIHSS is a clinical tool that can be used to - ANSWER A,B,D 2. Which of the following statements about NIHSS is not accurate? - ANSWER The NIHSS is a 10-item scale 3. The NIHSS can be completed by trained healthcare personnel in ....minutes. - ANSWER Under 7 4. What does NIHSS stand for? - ANSWER National Institute of Health Stroke Scale 5. What are 6 important conventions to remember when scoring a NIHSS? - ANSWER Administer scale items in EXACT order Avoid coaching the patient Accept the patient's first effort Score only what the patient does Be consistent Include all deficits in scoring 6. When administering an NIHSS what is important to remember about the order of the test? - ANSWER Do not change the order of the testing, go in exact order to reproduce results. 7. A nurse is administering a NIHSS. He/she re preforms the test after a poor first result. The patient scores much better on the second attempt. Which test result should the nurse record in the patient's records? Why? - ANSWER The first attempt. Only first attempts are recorded as an attempt to keep the NIHSS uniform throughout healthcare. 8. What is the first item of the NIHSS? 1A - ANSWER Level of Consciousness 9. How do you perform LOC item 1B? - ANSWER Ask the patient their age and the current month 10.How do you record the score on LOC item 1B? - ANSWER 0 = both questions are correct 1 = one answer is incorrect 2 = both questions are incorrect 11.When asking the patient's age, instead of a numerical value they give you their date of birth. Is that correct or incorrect? - ANSWER This is considered incorrect. 12.During questioning of the current month (we'll say it's currently January), the patient first says May and then corrects themselves and says January. How do you record this? - ANSWER This is considered an incorrect answer. Only accept the initial answer, and no partial credit is given. 13.How do you perform LOC item 1C? - ANSWER Instruct the patient to 'close their eyes, then open them up. Take your (unaffected) hand and make a fist, then open it up.' 14.How do you score LOC item 1C? - ANSWER 0 = both items performed correctly 1 = one item performed correctly 2 = both items performed incorrectly 15.In LOC item 1C can partial credit be given if the patient makes a legitmate effort that is impaired due to weakness? - ANSWER Yes 16.At what point should the pt suspected of having an ischemic stroke 1st be assessed using the NIHSS? - ANSWER As soon as he/she is stabilized. 17.A nurse administers the NIHSS to a pt who was brought to the ER by his son, who suspected that his father had a stroke. The nurse calculates the total NIHSS score of 12. What should this indicate to the nurse? - ANSWER The pt had a moderate stroke 18.The nurse ask the pt to read the list of words attached to the NIHSS. The pts speech is unintelligible. What score should the nurse assign based on this finding? - ANSWER 2 19.The nurse administering the NIHSS hold one finger up approximately one foot in front of pts face at eye level, instructs the pt to follow his finger with her eye, keeping the face still, as he moves his finger horizontally back and forth across the pts field of view. The nurse observes for voluntary or reflexive horizontal eye movement and assigns a score of 0. This indicates that - ANSWER The pt had normal horizontal eye movements 20.The nurse administering the NIHSS positions the supine pts left arm at a 45 angle from his body with the elbow straight and the palm down. She releases the arm and counts to 10. What is the nurse assessing for? - ANSWER Motor strength 21.The nurse is administering item 4 of the NIHSS. She asks the pt to show his teeth but the pt is unresponsive. What should the nurse do? - ANSWER Apply a noxious stimulus and observe for symmetry of the facial grimace 22.Which of the following is not likely to be among the tests used in the eval of a PT who is suspected of having a stroke. - ANSWER Cardiac cath 23.The NIHSS can be used to assess stroke severity and predict functional outcomes, but NIHSS scores cannot be used to predict mortality risk. - ANSWER FALSE 24.When providing education to the pt and family, the nurse should reinforce that if a stroke is suspected, they should dial 911 and seek medical help. - ANSWER TRUE 25.A nurse working at a designated stroke center should be aware that ....... is the maximum overall score on the NIHSS. - ANSWER 42