NIH Stroke Scale| All Test Groups|
Questions With 100% Correct Answers|
Graded A+
What effort should be recorded? Do not do what?
Right Answer - The patient's first effort. Don't go back and change scores.
IMPORTANT CONVENTIONS IN ADMINISTRATION:
Administer scale items in their exact ______
-Avoid ______ing patient
-Accept patient's _______ effort
-Score only what the patient _______
-Be consistent
-Include all _________s into scoring, including those that may be from
_________s ______s
Right Answer - -order
-coaching
-first
-does
-Be consistent
-previous strokes
ITEM 1a and how to get it
Right Answer - -examiner's overall impression of patient alertness
-ask 2-3 questions about circumstances of admission, stimuate patient by
patting or tapping, occasionally pinching
NIH Item 1a Scoring:
0
1
,2
3
Right Answer - -Alert
-Not alert, aroused w/ minor verbal stim
-Not alert, requires strong or painful stim
-Only reflexive movements or unresponsive
ITEM 1a - patient w/ 3 on this item is generally considered in...
3 is scored ONLY if patient does not move other than....
Right Answer - a coma
reflexive posturing in response to noxious stimulation
If difficult to determine 1 vs 2 in item 1a, continue with...
Right Answer - medical hx qs until confident in assigning a score - THIS IS
ONLY TIME IN NIH scale where you can go back
EVEN IF PRESENTED WITH OBSTACLES OR BARRIERS, YOU MUST
CHOOSE A
Right Answer - SCORE
NIH Item 1B
based on responses to two items:
When?
-What about patient
Right Answer - -month of year
-patient's age
ITEM 1B SCORING
0
1
2
Right Answer - -answers both qs correctly
, -answers 1 q correctly OR patients unable to communicate d/t intubation,
oral-tracheal trauma, severe dysarthria from any cause, language barrier,
or any issue not secondary to aphasia
-answers neither question correctly --> a 3 on 1a must be a 2 on 1b
A patient that cannot speak but is otherwise able to communicate can be
allowed to convey the Answer how?
Right Answer - writing
If the patient answers incorrectly first and then corrects self, how is the
Answer scored?
Right Answer - it is still scored as incorrect
What if patient gives DOB as Answer to question asking for their age? How
is this scored?
When answering what month it is, is there credit for partial answers that are
close like being off a month?
Right Answer - This is scored as a WRONG answer.
NO
NIH 1C is what?
Make sure to position what in testable position
Right Answer - Commands
Eyes and Hands
NIH 1C
ask patient to do how many actions and what are they?
Right Answer - 3 commands
"close your eyes for me"
"now open them"
"now make a fist with your hand"
NIH 1C - may I repeat the commands?
May I encourage?
May I pantomime command?
Questions With 100% Correct Answers|
Graded A+
What effort should be recorded? Do not do what?
Right Answer - The patient's first effort. Don't go back and change scores.
IMPORTANT CONVENTIONS IN ADMINISTRATION:
Administer scale items in their exact ______
-Avoid ______ing patient
-Accept patient's _______ effort
-Score only what the patient _______
-Be consistent
-Include all _________s into scoring, including those that may be from
_________s ______s
Right Answer - -order
-coaching
-first
-does
-Be consistent
-previous strokes
ITEM 1a and how to get it
Right Answer - -examiner's overall impression of patient alertness
-ask 2-3 questions about circumstances of admission, stimuate patient by
patting or tapping, occasionally pinching
NIH Item 1a Scoring:
0
1
,2
3
Right Answer - -Alert
-Not alert, aroused w/ minor verbal stim
-Not alert, requires strong or painful stim
-Only reflexive movements or unresponsive
ITEM 1a - patient w/ 3 on this item is generally considered in...
3 is scored ONLY if patient does not move other than....
Right Answer - a coma
reflexive posturing in response to noxious stimulation
If difficult to determine 1 vs 2 in item 1a, continue with...
Right Answer - medical hx qs until confident in assigning a score - THIS IS
ONLY TIME IN NIH scale where you can go back
EVEN IF PRESENTED WITH OBSTACLES OR BARRIERS, YOU MUST
CHOOSE A
Right Answer - SCORE
NIH Item 1B
based on responses to two items:
When?
-What about patient
Right Answer - -month of year
-patient's age
ITEM 1B SCORING
0
1
2
Right Answer - -answers both qs correctly
, -answers 1 q correctly OR patients unable to communicate d/t intubation,
oral-tracheal trauma, severe dysarthria from any cause, language barrier,
or any issue not secondary to aphasia
-answers neither question correctly --> a 3 on 1a must be a 2 on 1b
A patient that cannot speak but is otherwise able to communicate can be
allowed to convey the Answer how?
Right Answer - writing
If the patient answers incorrectly first and then corrects self, how is the
Answer scored?
Right Answer - it is still scored as incorrect
What if patient gives DOB as Answer to question asking for their age? How
is this scored?
When answering what month it is, is there credit for partial answers that are
close like being off a month?
Right Answer - This is scored as a WRONG answer.
NO
NIH 1C is what?
Make sure to position what in testable position
Right Answer - Commands
Eyes and Hands
NIH 1C
ask patient to do how many actions and what are they?
Right Answer - 3 commands
"close your eyes for me"
"now open them"
"now make a fist with your hand"
NIH 1C - may I repeat the commands?
May I encourage?
May I pantomime command?
