NIHSS Certification Exam Review – Questions With
Accurate Answers
What does NIHSS stand for? Right Ans - National Institute of Health Stroke
Scale
What are 6 important conventions to remember when scoring a NIHSS?
Right Ans - 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? Right Ans - 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? Right Ans -
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 Right Ans - Level of Consciousness
What are the four score levels for item 1A? Right Ans - 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? Right Ans - Rubbing on the
chest, painful stimuli
Accurate Answers
What does NIHSS stand for? Right Ans - National Institute of Health Stroke
Scale
What are 6 important conventions to remember when scoring a NIHSS?
Right Ans - 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? Right Ans - 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? Right Ans -
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 Right Ans - Level of Consciousness
What are the four score levels for item 1A? Right Ans - 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? Right Ans - Rubbing on the
chest, painful stimuli
