NIHSS Certification Exam Review

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NIHSS Certification Exam Review 1.What does NIHSS stand for ANS National Institute of Health Stroke Scale 2.What are 6 important conventions to remember when scoring a NIHSS 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 3.When administering an NIHSS what is important to remember about the order of the test ANS Do not change the order of the testing, go in exact order to reproduce results.

4.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 1 / 2

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ANS The first attempt. Only first attempts are recorded as an attempt to keep the NIHSS uniform throughout healthcare.

5.What is the first item of the NIHSS? 1A: Level of Consciousness

6.What are the four score levels for item 1A ANS 0 = Alert 1 = Not alert, aroused with minor verbal stimulation

• = Not alert; requires strong or painful stimulation
• = Reflex movements only or totally unresponsive

7.How should a level 3 patient be stimulated ANS Rubbing on the chest, painful stimuli 8.During a NIHSS the nurse is not sure whether to score the patient a 1 or a

• What should they do ANS Continue to ask the patient questions about

orientation until they are confident about which category to place them in.

9.What is important to remember reguarding score changing on item 1A ANS It is the only time you are allowed to go back and change a score.

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