NIHSS Motor Function Assessment 5

Question 1

A patient scores 2 on right arm motor, 1 on left arm motor, 2 on right leg motor, and 1 on left leg motor. What is the total motor subscore?

Accepted Answer

6

Answer

Adding the four motor scores: 2+1+2+1 = 6 total motor subscore.

Question 2

During NIHSS testing, a patient with right-sided weakness asks to use the left arm to 'show' what to do. How should the examiner respond?

Accepted Answer

Give verbal instruction and test the affected arm directly

Answer

The examiner should provide verbal instructions and test the affected limb directly, not allow the patient to demonstrate with the unaffected side.

Question 3

What happens to NIHSS motor scores if a patient spontaneously improves and holds the arm fully for 10 seconds on repeat testing?

Accepted Answer

The current best score is documented

Answer

Serial NIHSS scoring reflects the patient's current neurological status at the time of assessment.

Question 4

In a patient with bilateral motor weakness from basilar artery occlusion, how are both sides scored on NIHSS motor items?

Accepted Answer

Both sides are scored independently

Answer

All four motor items (right arm, left arm, right leg, left leg) are scored independently regardless of bilateral involvement.

Question 5

A nurse performs NIHSS and notes the arm drifts to the bed in 4 seconds. A physician retests and the arm holds for 6 seconds. Which score is correct for documentation?

Accepted Answer

The most recent examiner's finding is used

Answer

NIHSS scores reflect the most recent standardized assessment; serial exams replace prior scores for that time point.

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NIHSS Motor Function Assessment 5