NIHSS Certification Exam Review
Questions and Answers
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? - ANSWERS-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 - ANSWERS-Level of Consciousness
What are the four score levels for item 1A? - ANSWERS-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? - ANSWERS-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? - ANSWERS-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? - ANSWERS-It is the
only time you are allowed to go back and change a score.
Questions and Answers
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? - ANSWERS-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 - ANSWERS-Level of Consciousness
What are the four score levels for item 1A? - ANSWERS-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? - ANSWERS-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? - ANSWERS-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? - ANSWERS-It is the
only time you are allowed to go back and change a score.
