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NIHSS Certification Exam Review Already Passed
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
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. 1 / 2
What is the first item of the NIHSS? 1A ✔✔Level of Consciousness
What are the four score levels for item 1A? ✔✔0 = Alert
- = Not alert, aroused with minor verbal stimulation
- = Not alert; requires strong or painful stimulation
- = 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.
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