NIHSS GROUP C FINAL EXAM QUESTIONS WITH CORRECT DETAILED ANSWERS || ALREADY GRADED A+ RECENT VERSION

NIHSS GROUP C FINAL EXAM QUESTIONS WITH CORRECT DETAILED ANSWERS || ALREADY GRADED A+ RECENT VERSION What does NIHSS stand for? - ANSWER️National Institute of Health Stroke Scale What are 6 important conventions to remember when scoring a NIHSS? - ANSWER️Administer 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? - ANSWER️Do 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? - ANSWER️The 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 - ANSWER️Level of Consciousness What are the four score levels for item 1A? - ANSWER️0 = 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? - ANSWER️Rubbing 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? - ANSWER️Continue to ask the patient questions about orientation until they are confident about which category to place them in. The NIHSS can be completed by trained healthcare personnel in ....minutes. - ANSWER️Under 7 At what point should the pt suspected of having an ischemic stroke 1st be assessed using the NIHSS? - ANSWER️As soon as he/she is stabilized. 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? - ANSWER️The pt had a moderate stroke 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? - ANSWER️2 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 - ANSWER️The pt had normal horizontal eye movements 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? - ANSWER️Motor strength 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? - ANSWER️Apply a noxious stimulus and observe for symmetry of the facial grimace 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. - ANSWER️Cardiac cath The NIHSS can be used to assess stroke severity and predict functional outcomes, but NIHSS scores cannot be used to predict mortality risk. - ANSWER️FALSE 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. - ANSWER️TRUE A nurse working at a designated stroke center should be aware that ....... is the maximum overall score on the NIHSS. - ANSWER️42 While administering the NIHSS, the nurse asks the pt to open and close his eyes and to make a fist with one hand and then release the fist. If the pt is able to follow one command correctly, the nurse should assign a score of.. - ANSWER️1 What does NIHSS stand for? - ANSWER️National Institute of Health Stroke Scale What are 6 important conventions to remember when scoring a NIHSS? - ANSWER️Administer 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? - ANSWER️Do 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? - ANSWER️The 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 - ANSWER️Level of Consciousness What are the four score levels for item 1A? - ANSWER️0 = 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? - ANSWER️Rubbing 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? - ANSWER️Continue to ask the patient questions about orientation until they are confident about which category to place them in. The NIHSS can be completed by trained healthcare personnel in ....minutes. - ANSWER️Under 7 At what point should the pt suspected of having an ischemic stroke 1st be assessed using the NIHSS? - ANSWER️As soon as he/she is stabilized. 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? - ANSWER️The pt had a moderate stroke 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? - ANSWER️2 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 - ANSWER️The pt had normal horizontal eye movements 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? - ANSWER️Motor strength 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? - ANSWER️Apply a noxious stimulus and observe for symmetry of the facial grimace 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. - ANSWER️Cardiac cath The NIHSS can be used to assess stroke severity and predict functional outcomes, but NIHSS scores cannot be used to predict mortality risk. - ANSWER️FALSE 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. - ANSWER️TRUE A nurse working at a designated stroke center should be aware that ....... is the maximum overall score on the NIHSS. - ANSWER️42 While administering the NIHSS, the nurse asks the pt to open and close his eyes and to make a fist with one hand and then release the fist. If the pt is able to follow one command correctly, the nurse should assign a score of.. - ANSWER️1