NIHSS Certification Exam Review With complete solutions

What does NIHSS stand for? National Institute of Health Stroke Scale What are 6 important conventions to remember when scoring a NIHSS? 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 00:04 01:23 When administering an NIHSS what is important to remember about the order of the test? 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? 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 Level of Consciousness What are the four score levels for item 1A? 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? 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? 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? It is the only time you are allowed to go back and change a score. How do you perform LOC item 1B? Ask the patient their age and the current month How do you record the score on LOC item 1B? 0 = 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? This 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? This is considered an incorrect answer. Only accept the initial answer, and no partial credit is given. How do you perform LOC item 1C? Instruct the patient to 'close their eyes, then open them up. Take your (unaffected) hand and make a fist, then open it up.' How do you score LOC item 1C? 0 = both items performed correctly 1 = one item performed correctly 2 = both items performed incorrectly In LOC item 1C can partial credit be given if the patient makes a legitmate effort that is impaired due to weakness? Yes The patient does not speak English. Their family who is bilingual is in the room. How will you instruct the patient for LOC item 1C? You are able to ask the family to give verbal commands to the patient and observe the response. What is the best gaze item? It tests horizontal gaze How do you test for best gaze? First observe the patient's eye movements. Note any shaking or inability to focus. Then instruct the patient to follow your finger from right to left with just their eyes. What is the scoring for best gaze? 0 = patient performs correctly 1 = partial gaze palsy 2 = patient cannot perform