NIHSS || QUESTIONS WITH COMPLETE
SOLUTIONS!!
If a patient is not following commands, how can you assess visual fields? correct answers
Visual Threat:
0 - pt blinking in both eyes to threat
2 - blinks in only one eye
3 - patient is blind
Extinction / Inattention correct answers Have pt look at yr nose, hold both hands up and
wiggle one hand.
Ask pt to point to hand that is moving.
Wiggle both hands and ask pt to point or state which hands are moving.
Have pt close eyes, ask them to tell you which side you are touching or tapping: R, L, or
both.
Check on pt's cheeks, arms, and legs.
0 - normal
1 - pt cannot see / feel both sides when hands are wiggling OR when pt is being touched both
sides at same time
2 pt cannot see both sides AND pt cannot feel both sides at same time
If pt has severe vision loss but no other issues w/ identifying stimulation - Score 0
Pt cannot follow commands - Score 0
Inattention correct answers
For NIHSS, a higher score signifies... correct answers more deficits (worse condition)
Level of Consciousness Test correct answers Observe pt's alertness
Call pt by name to awaken if asleep
If no response, physical stimulation
0 - alert
1 - arouses to minor stimulation
2 - needs repeated stimulation to arouse
3 - only responds w/ reflex motor/autonomic effects
Level of Consciousness Questions correct answers What month is it?
How old are you?
0 - both answered correctly
1 - one answered correctly
2 - both answers wrong
For aphasic pts: give options, ask pt to nod at correct option
Level of Consciousness Commands correct answers Ask pt to follow 2 simple commands
(e.g. open and close eyes, grip hand)
SOLUTIONS!!
If a patient is not following commands, how can you assess visual fields? correct answers
Visual Threat:
0 - pt blinking in both eyes to threat
2 - blinks in only one eye
3 - patient is blind
Extinction / Inattention correct answers Have pt look at yr nose, hold both hands up and
wiggle one hand.
Ask pt to point to hand that is moving.
Wiggle both hands and ask pt to point or state which hands are moving.
Have pt close eyes, ask them to tell you which side you are touching or tapping: R, L, or
both.
Check on pt's cheeks, arms, and legs.
0 - normal
1 - pt cannot see / feel both sides when hands are wiggling OR when pt is being touched both
sides at same time
2 pt cannot see both sides AND pt cannot feel both sides at same time
If pt has severe vision loss but no other issues w/ identifying stimulation - Score 0
Pt cannot follow commands - Score 0
Inattention correct answers
For NIHSS, a higher score signifies... correct answers more deficits (worse condition)
Level of Consciousness Test correct answers Observe pt's alertness
Call pt by name to awaken if asleep
If no response, physical stimulation
0 - alert
1 - arouses to minor stimulation
2 - needs repeated stimulation to arouse
3 - only responds w/ reflex motor/autonomic effects
Level of Consciousness Questions correct answers What month is it?
How old are you?
0 - both answered correctly
1 - one answered correctly
2 - both answers wrong
For aphasic pts: give options, ask pt to nod at correct option
Level of Consciousness Commands correct answers Ask pt to follow 2 simple commands
(e.g. open and close eyes, grip hand)
