NIHSS FINAL EXAM QUESTIONS 2025/2026 WITH CORRECT DETAILED ANSWERS ALREADY GRADED A+ RECENT VERSION

NIHSS FINAL EXAM QUESTIONS 2025/2026 WITH CORRECT DETAILED ANSWERS ALREADY GRADED A+ RECENT VERSION Dysarthria NIHSS Scoring - ANSWER. If the patient is thought to be normal, an adequate sample of speech must be obtained by asking the patient to read or repeat words from the list. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated. Only if the patient is intubated or has other physical barriers to producing speech, the examiner should record the score as untestable (UN) Do not tell the patient why he or she is being tested 0 - Normal 1 - Mild-to-moderate dysarthria; patient slurs at least some words and, at worst, can be understood with some difficulty 2 - Severe dysarthria; patient's speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric UN - Intubated or other physical barrier Extinction and Inattention NIHSS Scoring - ANSWERPSince the abnormality is scored only if present, the item is never untestable 0 - No abnormality 1 - Visual, tactile, auditory, spatial, or personal inattention, or extinction to bilateral simultaneous stimulation in one of the sensory modalities 2 - Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space NIHSS - ANSWERPA standardized assessment comprising 15 item groups into 11 domains, including three separate LOC items (responsiveness, questions, commands)--to accurately quantify stroke severity, communicate deficits precisely, and track neurological changes that influence treatment decisions. Mild moderate severe very severe - ANSWERPClassify NIHSS score ranges: 0-4 5-15 16-20 20 tPA eligibility - ANSWERPWhat often hinges on NIHSS score and clinical context? The healthcare professional is evaluating the Motor Leg function. The examiner positions the leg in the correct position and then releases the leg. The leg slightly dips, returns to a normal position, and the position is held up for 5 seconds. What is the appropriate score? - ANSWERP0 â€" No drift What is item 2 (Best Gaze) designed to test? - ANSWERPHorizontal eye movement only True or False: One clinical application of the NIHSS is to assess patients before they receive tissue plasminogen activator (tPA). - ANSWERPTRUE What technique is used to assess visual extinction, which involves the examiner placing their fingers in the patient's visual fields at the same time? - ANSWERPDouble simultaneous stimulation What does NIHSS stand for? - ANSWERPNational Institute of Health Stroke Scale What are 6 important conventions to remember when scoring an NIHSS? - ANSWERPAdminister 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? - ANSWERPDo not change the order of the testing; go in exact order to reproduce results. A nurse is administering an NIHSS. He/she reperforms 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? - ANSWERPThe 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 - ANSWERPLevel of Consciousness What are the four score levels for item 1A? - ANSWERP0 = 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? - ANSWERPRubbing on the chest, painful stimuli During an NIHSS, the nurse is not sure whether to score the patient a 1 or a 2. What should they do? - ANSWERPContinue to ask the patient questions about orientation until they are confident about which category to place them in. What is important to remember regarding score changing on item 1A? - ANSWERPIt is the only time you are allowed to go back and change a score. How do you perform LOC item 1B? - ANSWERPAsk the patient their age and the current month How do you record the score on LOC item 1B? - ANSWERP0 = both questions are correct 1 = one answer is incorrect 2 = both questions are incorrect When asking the patient's age, instead of a numerical value, they give you their date of birth. Is that correct or incorrect? - ANSWERPThis is considered incorrect. During questioning of the current month (we'll say it's currently January), the patient first says May and then corrects themselves and says January. How do you record this? - ANSWERPThis is considered an incorrect answer. Only accept the initial answer, and no partial credit is given. How do you perform LOC item 1C? - ANSWERPInstruct the patient to 'close their eyes, then open them up. Take your (unaffected) hand and make a fist, then open it up.'