NIH Stroke Scale (NIHSS) Certification Answer Key | Groups
A–F (Patients 1–6) | 2026/2027 Edition
Complete Answer Key | Verified and Fully Updated
PATIENT A (Group A) – Case Description
A 68-year-old male, 4 hours post-onset of right hemisphere stroke. Presents with
left-sided weakness and neglect.
1a. Level of Consciousness (LOC)
Clinical Observation: The patient is alert, eyes open spontaneously, and tracks the
examiner appropriately. He responds immediately to verbal stimuli without prompting.
Scoring Options:
● A. 0 - Alert; keenly responsive. [CORRECT]
● B. 1 - Not alert; but arousable with minor stimulation.
● C. 2 - Not alert; requires repeated stimulation, obtunded.
● D. 3 - Unresponsive or reflex responses only.
Correct Answer: 0
Rationale: Per NIHSS instructions, score 0 indicates the patient is "alert, keenly
responsive." The patient demonstrates spontaneous eye opening, appropriate tracking,
and immediate responsiveness without requiring external stimulation. No evidence of
drowsiness or obtundation is present. Scores 1-3 are reserved for patients with
diminished arousal requiring stimulation or unresponsiveness.
1b. LOC Questions
,Clinical Observation: Ask the patient: "What is your age?" and "What month is it?" The
patient correctly states his age as 68 but incorrectly states the month is February when
it is actually March.
Scoring Options:
● A. 0 - Answers both questions correctly.
● B. 1 - Answers one question correctly. [CORRECT]
● C. 2 - Answers neither question correctly.
Correct Answer: 1
Rationale: NIHSS rules require both questions to be answered correctly for a score of 0.
The patient correctly answered one question (age) but failed the other (month). Score 1
is assigned when "answers one question correctly." Score 2 would apply only if both
answers were incorrect (e.g., wrong age and wrong month), which is not the case here.
1c. LOC Commands
Clinical Observation: Ask the patient to "Open and close your eyes" and "Grip and
release your non-paretic hand." The patient correctly opens and closes his eyes but is
unable to grip and release with his right hand (due to weakness), though he attempts
the movement.
Scoring Options:
● A. 0 - Performs both tasks correctly.
● B. 1 - Performs one task correctly. [CORRECT]
● C. 2 - Performs neither task correctly.
Correct Answer: 1
Rationale: The patient successfully completed one command (eye opening/closing) but
could not complete the second due to motor impairment. Per NIHSS instructions, if a
,patient cannot complete the second task due to weakness, score 1: "Performs one task
correctly." The attempt to move the weak limb confirms comprehension. Score 2 would
apply only if the patient failed both tasks due to comprehension deficits or did not
attempt either.
2. Best Gaze
Clinical Observation: Hold your finger horizontally approximately 12 inches from the
patient's face in the midline. Move your finger slowly to the left, then to the right. The
patient's eyes move fully to the right but do not move past midline when attempting to
gaze to the left. There is no forced deviation or spontaneous eye movement to the left.
Scoring Options:
● A. 0 - Normal.
● B. 1 - Partial gaze palsy; gaze is abnormal in one or both eyes, but forced
deviation or total gaze paresis is not present. [CORRECT]
● C. 2 - Forced deviation, or total gaze paresis not overcome by the oculocephalic
maneuver.
Correct Answer: 1
Rationale: The patient demonstrates partial gaze palsy—impaired conjugate eye
movement to the left but not a complete absence of movement or forced deviation.
Score 1 applies when "gaze is abnormal in one or both eyes, but forced deviation or total
gaze paresis is not present." Score 2 requires either forced deviation (eyes fixed in one
direction) or total gaze paresis that cannot be overcome by oculocephalic maneuver,
which is not described here.
3. Visual Fields
, Clinical Observation: Test visual fields by confrontation in both eyes. The patient
correctly identifies your finger when presented in the right upper and lower quadrants.
When presented in the left upper and lower quadrants, the patient consistently fails to
detect your finger unless it is brought close to the midline. There is no evidence of
extinction with simultaneous stimulation.
Scoring Options:
● A. 0 - No visual loss.
● B. 1 - Partial hemianopia. [CORRECT]
● C. 2 - Complete hemianopia.
● D. 3 - Bilateral hemianopia (blind including cortical blindness).
Correct Answer: 1
Rationale: The patient demonstrates partial left hemianopia—visual field loss in the left
hemifield that is not complete (can detect stimuli near the midline). NIHSS score 1
indicates "partial hemianopia." Score 2 (complete hemianopia) would require no
detection of stimuli in the affected hemifield even when brought to the midline. Score 3
requires bilateral involvement, which is absent here.
4. Facial Palsy
Clinical Observation: Ask the patient to show their teeth or smile, raise eyebrows, and
close eyes tightly. The nasolabial fold is flattened on the left, and the left corner of the
mouth does not elevate with smiling. The patient can partially close the left eye but not
as tightly as the right. Forehead wrinkling is preserved bilaterally.
Scoring Options:
● A. 0 - Normal symmetrical movements.
● B. 1 - Minor paralysis (flattened nasolabial fold, asymmetry on smiling).
[CORRECT]
A–F (Patients 1–6) | 2026/2027 Edition
Complete Answer Key | Verified and Fully Updated
PATIENT A (Group A) – Case Description
A 68-year-old male, 4 hours post-onset of right hemisphere stroke. Presents with
left-sided weakness and neglect.
1a. Level of Consciousness (LOC)
Clinical Observation: The patient is alert, eyes open spontaneously, and tracks the
examiner appropriately. He responds immediately to verbal stimuli without prompting.
Scoring Options:
● A. 0 - Alert; keenly responsive. [CORRECT]
● B. 1 - Not alert; but arousable with minor stimulation.
● C. 2 - Not alert; requires repeated stimulation, obtunded.
● D. 3 - Unresponsive or reflex responses only.
Correct Answer: 0
Rationale: Per NIHSS instructions, score 0 indicates the patient is "alert, keenly
responsive." The patient demonstrates spontaneous eye opening, appropriate tracking,
and immediate responsiveness without requiring external stimulation. No evidence of
drowsiness or obtundation is present. Scores 1-3 are reserved for patients with
diminished arousal requiring stimulation or unresponsiveness.
1b. LOC Questions
,Clinical Observation: Ask the patient: "What is your age?" and "What month is it?" The
patient correctly states his age as 68 but incorrectly states the month is February when
it is actually March.
Scoring Options:
● A. 0 - Answers both questions correctly.
● B. 1 - Answers one question correctly. [CORRECT]
● C. 2 - Answers neither question correctly.
Correct Answer: 1
Rationale: NIHSS rules require both questions to be answered correctly for a score of 0.
The patient correctly answered one question (age) but failed the other (month). Score 1
is assigned when "answers one question correctly." Score 2 would apply only if both
answers were incorrect (e.g., wrong age and wrong month), which is not the case here.
1c. LOC Commands
Clinical Observation: Ask the patient to "Open and close your eyes" and "Grip and
release your non-paretic hand." The patient correctly opens and closes his eyes but is
unable to grip and release with his right hand (due to weakness), though he attempts
the movement.
Scoring Options:
● A. 0 - Performs both tasks correctly.
● B. 1 - Performs one task correctly. [CORRECT]
● C. 2 - Performs neither task correctly.
Correct Answer: 1
Rationale: The patient successfully completed one command (eye opening/closing) but
could not complete the second due to motor impairment. Per NIHSS instructions, if a
,patient cannot complete the second task due to weakness, score 1: "Performs one task
correctly." The attempt to move the weak limb confirms comprehension. Score 2 would
apply only if the patient failed both tasks due to comprehension deficits or did not
attempt either.
2. Best Gaze
Clinical Observation: Hold your finger horizontally approximately 12 inches from the
patient's face in the midline. Move your finger slowly to the left, then to the right. The
patient's eyes move fully to the right but do not move past midline when attempting to
gaze to the left. There is no forced deviation or spontaneous eye movement to the left.
Scoring Options:
● A. 0 - Normal.
● B. 1 - Partial gaze palsy; gaze is abnormal in one or both eyes, but forced
deviation or total gaze paresis is not present. [CORRECT]
● C. 2 - Forced deviation, or total gaze paresis not overcome by the oculocephalic
maneuver.
Correct Answer: 1
Rationale: The patient demonstrates partial gaze palsy—impaired conjugate eye
movement to the left but not a complete absence of movement or forced deviation.
Score 1 applies when "gaze is abnormal in one or both eyes, but forced deviation or total
gaze paresis is not present." Score 2 requires either forced deviation (eyes fixed in one
direction) or total gaze paresis that cannot be overcome by oculocephalic maneuver,
which is not described here.
3. Visual Fields
, Clinical Observation: Test visual fields by confrontation in both eyes. The patient
correctly identifies your finger when presented in the right upper and lower quadrants.
When presented in the left upper and lower quadrants, the patient consistently fails to
detect your finger unless it is brought close to the midline. There is no evidence of
extinction with simultaneous stimulation.
Scoring Options:
● A. 0 - No visual loss.
● B. 1 - Partial hemianopia. [CORRECT]
● C. 2 - Complete hemianopia.
● D. 3 - Bilateral hemianopia (blind including cortical blindness).
Correct Answer: 1
Rationale: The patient demonstrates partial left hemianopia—visual field loss in the left
hemifield that is not complete (can detect stimuli near the midline). NIHSS score 1
indicates "partial hemianopia." Score 2 (complete hemianopia) would require no
detection of stimuli in the affected hemifield even when brought to the midline. Score 3
requires bilateral involvement, which is absent here.
4. Facial Palsy
Clinical Observation: Ask the patient to show their teeth or smile, raise eyebrows, and
close eyes tightly. The nasolabial fold is flattened on the left, and the left corner of the
mouth does not elevate with smiling. The patient can partially close the left eye but not
as tightly as the right. Forehead wrinkling is preserved bilaterally.
Scoring Options:
● A. 0 - Normal symmetrical movements.
● B. 1 - Minor paralysis (flattened nasolabial fold, asymmetry on smiling).
[CORRECT]
