What is the purpose of the NIH Stroke Scale and how should ED nurses use it?

• A. To assess cardiac function in stroke patients.
• B. To quantify stroke severity, guide thrombolysis decisions, track progress, and document baseline for comparison.
• C. To predict hemorrhagic risk in stroke.
• D. To measure blood glucose levels in stroke patients.

Answer: (B)

The NIH Stroke Scale measures how severe a stroke is by turning neurologic findings into a numeric score, giving a standardized way to gauge deficit. In the ED, this score helps guide urgent decisions about reperfusion therapy, particularly intravenous thrombolysis, and it provides a baseline that can be referenced as the patient’s status changes. Tracking the score over time shows improvement or deterioration, informing imaging decisions, transfer needs, and treatment adjustments. It’s not a tool for cardiac function, hemorrhagic risk, or glucose measurement. When using it, ED nurses should perform a prompt, standardized assessment on arrival, document the total score accurately, and reassess at defined intervals to monitor trajectory and effectiveness of interventions.