NIHSS Practice Quiz (What questions to ask)

Components of NIHSS - Answer- Wakefulness (Q1ABC) Vision (Q3) Motor (Q2,4567) Sensory (Q8,11) Language and Speech (9,10) Q1ABC - Wakefulness - Answer- 1a-are they immediately awake or otherwise engage them. (responsiveness) 1b-correctly state age and current month (questions) 1c-open/close eyes AND squeeze hand (commands) Q2-Motor - Answer- "Keep your head straight and keep your eyes on my finger?" Horizontal eye movement Q3-Visual field test - Answer- "Cover your left eye? How many fingers can you see?" Assess accuracy of vision. If they can't perform it, then use visual threat and check if they blink. Q456-Motor - Answer- 4-Facial Palsy: "Raise eyebrows and show me your teeth." Look for droopiness in face or mouth 5-"Lift your left arm/Lift your right arm/Lift your left or right leg) 10 sec vs 5 sec. Q7-Motor coordination - Answer- "Touch your nose and touch my finger." "Can you slide your heel up and down your opposite leg?" Weakness versus ataxia Heel to shin test. Q8-Sensory - Answer- "Close your. Can you feel this? Does it feel the same or different on each side?" Test sense of pinprick (ability to withdraw from noxious stimuli if pt is obtunded or aphasic). 0=normal sensation 1=pt feels pin, but is dull