NIHSS Certification questions /correct answers updated/2024-2025, Exams of Nursing

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NIHSS Certification questions /correct answers updated/2024-

1. 11 components of NIHSS: 1. LOC (Question & Command) 2.Gaze 3.Visual field 4.Facial palsy 5.Upper extremity 6.Lower extremity 7.Limb ataxia 8.Sensory 9.Best language 10.Dysarthria 11.Extinction & inattention
2. 1A - LOC: 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 (COMA ~ try rub on chest)

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1a. Level of Consciousness: The investigator must choose a response, even if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation.*

3. 1B - LOC Questions (2): Month of year Patient age 0 = Answers both questions correctly 1 = Answers one question correctly 2 = Answers neither question correctly

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1b. LOC Questions: The patient is asked the month and his/her age. The answer must be correct - there is no partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from any cause, language barrier or any other problem not secondary to

aphasia are given a 1. It is important that only the initial answer be graded and that the examiner not "help" the patient with verbal or non-verbal cues.*

4. 1C - LOC Commands: Two tasks

• Close your eye for me and now open
• Make a fist with your hand LEVEL OF CONSCIOUSNESS: COMMANDS 0 = Performs both tasks correctly 1 = Performs one task correctly 2 = Performs neither task correctly

1c. LOC Commands: The patient is asked to open and close the eyes and then to grip and release the non-paretic hand. Substitute another one step command if the hands cannot be used. Credit is given if an unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, the task should be demonstrated to them (pantomime) and score the result (i.e., follows none, one or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored.*

5. Oculocephalic Maneuver: "Doll eyes" in comatose patient Used to determine whether vestibule-ocular reflex pathway from medulla to the midbrain is intact
6. 2. Best Gaze: Tests horizontal eye movement. Ask pt to follow finger 0 = Normal 1 = Partlal gaze palsy 2 = Forced deviation

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Best Gaze: Only horizontal eye movements will be tested. Voluntary or reflexive (oculocephalic) eye movements will be scored but caloric testing is not done. If the patient has a conjugate deviation of the eyes that can be overcome by voluntary or reflexive activity, the score will be 1. If a patient has an isolated peripheral nerve paresis (CN III, IV or VI) score a 1. Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, pre-existing blindness or other disorder of visual acuity or fields should be tested with reflexive movements and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy.*

7. 3 Visual Fields: *Count fingers in all four quadrants *Ask pt to look into your own eye

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O = No visual loss 1 = Partial hemianopia 2 = Complete hemianopia 3 = Bilateral hemianopia (blind including cortical blindness)

If extinquished, visual field scores one, even if field intach to confrontation

Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat as appropriate. Patient must be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored.

• Score 1 only if a clear-cut asymmetry, including quadrantanopia is found.
• If patient is blind from any cause score 3. Double simultaneous stimulation is performed at this point. If there is extinction patient receives a 1, and the results are used to answer question 11.*

8. 4 Facial palsy: 1. show me teeth, show me gum 2.close eye tight 3.Raise eyebrow up

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0 = Normal 1 = Minor paralysis ~ e.g. flatten nasolabial fold or mild asymmetry 2 = Partial paralysis ~ e.g. lower face involved paralysis 3 = Complete paralysis ~ e.g. obtunded or comatose pt

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Ask, or use pantomime to encourage the patient to show teeth or raise eyebrows and close eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non- comprehending patient. If facial trauma/bandages, orotracheal tube, tape or other physical barriers obscure the face, these should be removed to the extent possible.*

9. 5. Arm motor: Supine arm ~ 45* Sitting arm ~ 90* Arm drift ~ fall in 10 sec Leg drift ~ fall in 5 sec The initial dip is normal, continuous is not 5A (left arm) 5 B (right arm)

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0 = N0 drift 1 = Drift (slightly downward movement after the initial dip) 2 = Some effort against gravity 3 = No effort against gravity (able to shoulder shrugg) 4 = No voluntary movement Exceptions Item not scored if lost of consciousness

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The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN).*

10. 6. Motor Leg: Leg tested in supine position Falls in 5 sec Test nonparasitic limb first Leg hold at 30* angle 6A - L 6B - R 0 = N0 drift 1 = Drift (slightly downward movement after the initial dip) 2 = Some effort against gravity (hits the bed [support]) 3 = No effort against gravity 4 = No voluntary movement

Exceptions Item not scored if lost of consciousness

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The limb is placed in the appropriate position: hold the leg at 30 degrees (always tested supine). Drift is scored if the leg falls before 5 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic leg. Only in the case of amputation or joint fusion at the hip, the examiner should record the score as untestable (UN).*

11. 7 - Limb Ataxia: Test unilateral cerebellar lesion ~ scored only if ataxia is present and out of proportion to weakness

• Attempt incoordination vs general weakness Done by B/L Finger to nose & Heel to shin test *If pt has visual field not intact, test the pt in patients intact visual field *Case: Amputation or joint effusion, mark untestable

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0 = Absent (if significant weakness, = 0) 1 = Present in one limb (ataxia, dysmetria, dyssynergia in one limb) 2 = Present In two limbs (ataxia, dysmetria, dyssynergia in one limb)

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Dysmetria: inability to control the distance, power, and speed of a muscular action (inability to stop a movement at the intended target) dyssynergia: Impaired ability to associate muscles together for complex movement

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This item is aimed at finding evidence of a unilateral cerebellar lesion. Test with eyes open. In case of visual defect, ensure testing is done in intact visual field. The finger-nose-finger and heel-shin tests are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN), and clearly write

the explanation for this choice. In case of blindness, test by having the patient touch nose from extended arm position.*

12. 8 Sensory: Use pin pricks in the proximal portion of all four limbs & face

• ask stimuli
• eye not closed
• symmetric?
• in obtunded pt, obsevre for grimace
• don't test distal (e.g. hand)
• Even in aphasic or stuporous pt with noxious stimuli (nail bed)

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0 = Normal 1 = Mild-to-moderate sensory loss 2 = Severe or total sensory loss (if bilateral lost) Exceptions

• Pt with 3 on Level of conscious 1A (command) ~ will be scored as 2 here. [1A - 3 = Reflex movements only or totally unresponsive (COMA ~ try rub on chest)]

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Sensation or grimace to pinprick when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. Only sensory loss attributed to stroke is scored as abnormal and the examiner should test as many body areas (arms [not hands], legs, trunk, face) as needed to accurately check for hemisensory loss. A score of 2, "severe or total sensory loss," should only be given when a severe or total loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will, therefore, probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item.*

13. 9 Best language: - Language comprehension

• Listen to this while performing the entire exam

*Intubated pt should write down the response.

• Test by 1.Examing the cookie jar on the standard naming card 2.Reading series of sentences on the stroke card

*Have pt wear glass if he needs.

• Ask pt to describe meaning & action on cookie card.
• Read the sentence

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Scoring O = No aphasia 1 = Mild-to-moderate aphasia (loss of fluency) 2 = Severe aphasia (fragmented response or can not understand) 3 = Mute, global aphasia (no comprehension demonstrated e.g. stupor) Exceptions 3 on 1A scores 3 in this section

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A great deal of information about comprehension will be obtained during the preced- ing sections of the examination. For this scale item, the patient is asked to describe what is happening in the attached picture, to name the items on the attached naming sheet and to read from the attached list of sentences. Comprehension is judged from responses here, as well as to all of the commands in the preceding general neurological exam. If visual loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech. The intubated patient should be asked to write. The patient in a coma (item 1a=3) will automatically score 3 on this item. The examiner must choose a score for the patient with stupor o.*

14. 10 Dysarthria (difficulty forming words - articulation and clarity): - Read or repeat the name from stroke card MAMA TIP - TOP FIFTY - FIFTY THANKS HUCKLEBERRY BASEBALL PLAYER 0 2 Normal 1 = Mlld-to-moderato slurrlng 2 = Severe slurring (cant form or mute)

Exceptions Unresponsive = score 2 3 on LoC 1A = 2 here Untestable if intubated or has barrier to form speach

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If patient is thought to be normal, an adequate sample of speech must be obtained by asking patient to read or repeat words from the attached 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), and clearly write an explanation for this choice. Do not tell the patient why he/she is being tested.*

15. 11. Extinction & Inattention: Test neglect and inattention

• Done by double simultaneous stimulation if the above 2 are not clear from the conversation
• Followed by finger movement to pt's all visual fields (finger wiggle on right side, left side or both sides (both eyes open))
• wise to cdouble check if pt has obvious Anosognosia or neglect *alternatively touch limb then touch both sides. With eyes closed Neglect is only scored if present, so score is always tesable

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0 = No abnormality 1 = Visual, tactile, auditory, spatial or personal inattention 2 = Profound hemi-inattention or extinction to more than one modality (visual, spatial, tactile, auditory Exception 3 on LOC 1A = 2 automatically

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Anosognosia, also called "lack of insight,"

Sufficient information to identify neglect may be obtained during the prior testing. If the patient has a severe visual loss preventing visual double simultaneous stimula- tion, and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia but does appear to attend to both sides, the score is normal. The presence of visual spatial neglect or anosagnosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable.*

16. Anogsognosia: