NIHSS GROUP A EXAM PREP 2026 TEST PAPER
QUESTIONS AND SOLUTIONS ALREADY
PASSED
● 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
● 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.
● 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.
, ● What is the first item of the NIHSS? 1A Answer: Level of
Consciousness
● What are the four score levels for item 1A? Answer: 0 = Alert
1 = Not alert, aroused with minor verbal stimulation
2 = Not alert; requires strong or painful stimulation
3 = Reflex movements only or totally unresponsive
● How should a level 3 patient be stimulated? Answer: Rubbing on the
chest, painful stimuli
● During a NIHSS the nurse is not sure whether to score the patient a 1
or a 2. What should they do? Answer: Continue to ask the patient
questions about orientation until they are confident about which category
to place them in.
● What is important to remember reguarding score changing on item
1A? Answer: It is the only time you are allowed to go back and change a
score.
QUESTIONS AND SOLUTIONS ALREADY
PASSED
● 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
● 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.
● 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.
, ● What is the first item of the NIHSS? 1A Answer: Level of
Consciousness
● What are the four score levels for item 1A? Answer: 0 = Alert
1 = Not alert, aroused with minor verbal stimulation
2 = Not alert; requires strong or painful stimulation
3 = Reflex movements only or totally unresponsive
● How should a level 3 patient be stimulated? Answer: Rubbing on the
chest, painful stimuli
● During a NIHSS the nurse is not sure whether to score the patient a 1
or a 2. What should they do? Answer: Continue to ask the patient
questions about orientation until they are confident about which category
to place them in.
● What is important to remember reguarding score changing on item
1A? Answer: It is the only time you are allowed to go back and change a
score.
