APEX NIH Stroke Scale Group A – Patients 1–6 (2026/2027
Edition)
Complete Certification Exam Simulation – Verified Answers & Scoring
Rationales
APEX Innovations | NIH Stroke Scale International Certification Standards
Section 1: Patient 1 – Acute Ischemic Stroke, Right Hemisphere, Moderate
Deficits
Patient Profile: 68-year-old male, 4 hours post-symptom onset, alert but with left-sided
weakness and sensory changes.
Q1: Patient 1: Level of Consciousness (1a)
The examiner approaches the bed and observes the patient. The patient opens eyes
spontaneously when the examiner enters the room, is fully oriented to person, place,
and time, and engages in appropriate conversation. How should the nurse score this
item?
A. 0 – Alert; keenly responsive [CORRECT]
B. 1 – Not alert; but arousable with minor stimulation
C. 2 – Not alert; requires repeated stimulation
D. 3 – Coma; unresponsive or reflex responses only
Correct Answer: A
NIHSS Domain: 1a. Level of Consciousness
Score Range: 0–3
Rationale: [CORRECT] A (Score 0): The patient demonstrates all criteria for Score 0: eyes
open spontaneously, fully oriented, and appropriate interaction. No stimulation was
required to elicit attention. B (Score 1): Incorrect — patient does not require any
,stimulation to maintain alertness. C (Score 2): Incorrect — patient is not obtunded or
requiring repeated stimulation. D (Score 3): Incorrect — patient is clearly responsive and
interactive, not comatose. Common error: Scoring 1 because patient had stroke; NIHSS
LOC scoring is based on observed responsiveness, not diagnosis.
Q2: Patient 1: LOC Questions (1b)
The examiner asks: "What month is it?" The patient responds correctly. The examiner
asks: "How old are you?" The patient pauses, then states, "I'm... I'm not sure. Sixty...
something?" and cannot provide exact age. How should the nurse score this item?
A. 0 – Answers both questions correctly
B. 1 – Answers one question correctly [CORRECT]
C. 2 – Answers neither question correctly
D. Untestable (aphasic, intubated, etc.)
Correct Answer: B
NIHSS Domain: 1b. LOC Questions
Score Range: 0–2
Rationale: [CORRECT] B (Score 1): The patient answered the month correctly but failed
to provide correct age (even approximate decade is insufficient — exact age or close
approximation required). NIHSS allows credit for one correct answer only if both are
asked. A (Score 0): Incorrect — age was not answered correctly. C (Score 2): Incorrect —
one question was answered correctly. D: Incorrect — patient is able to respond verbally;
not untestable. Common error: Accepting "sixty-something" as correct; NIHSS requires
accurate age within 1-2 years or clear knowledge of one's age.
Q3: Patient 1: LOC Commands (1c)
The examiner instructs: "Open and close your eyes." The patient complies correctly. The
examiner then says: "Grip and release my hand." The patient looks confused, makes no
movement. The examiner repeats the command once. The patient slowly reaches out
,and grips with the right hand but does not release on command. How should the nurse
score this item?
A. 0 – Performs both tasks correctly
B. 1 – Performs one task correctly [CORRECT]
C. 2 – Performs neither task correctly
D. Untestable (amputation, trauma, etc.)
Correct Answer: B
NIHSS Domain: 1c. LOC Commands
Score Range: 0–2
Rationale: [CORRECT] B (Score 1): The eye command was performed correctly. The
grip/release command was not performed correctly — the patient required repetition,
used the wrong hand (right instead of left, which is paretic), and failed to release. Only
one task performed correctly = Score 1. A: Incorrect — grip/release was not correct. C:
Incorrect — eye task was correct. D: Incorrect — no physical barrier to testing. Common
error: Scoring 0 because patient "eventually" gripped; NIHSS requires correct performance
on first attempt after single repetition if needed.
Q4: Patient 1: Best Gaze (2)
The examiner asks the patient to follow a finger with eyes only, moving horizontally to
both sides. The patient's eyes follow to the right (toward the patient's right, examiner's
left) but do not cross midline when moving to the left. The examiner performs the
vertical gaze test — eyes move up and down normally. How should the nurse score this
item?
A. 0 – Normal
B. 1 – Partial gaze palsy; gaze 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 oculocephalic maneuver
D. Untestable
Correct Answer: B
, NIHSS Domain: 2. Best Gaze
Score Range: 0–2
Rationale: [CORRECT] B (Score 1): The patient demonstrates partial gaze palsy —
impaired gaze to the left (toward the side of the hemiparesis) but not forced deviation.
Eyes can be brought past midline with effort or reflex testing, but voluntary gaze is
impaired. Vertical gaze is intact. A: Incorrect — gaze abnormality is present. C: Incorrect
— forced deviation (Score 2) would show eyes fixed in one direction, not overcome by
voluntary effort or oculocephalic maneuver. D: Incorrect — patient is able to participate.
Common error: Scoring 0 because vertical gaze is normal; NIHSS horizontal gaze is the
primary assessment, and any abnormality = at least Score 1.
Q5: Patient 1: Visual Fields (3)
The examiner tests visual fields by confrontation. When testing the left visual field of
both eyes (temporal field of left eye, nasal field of right eye), the patient does not detect
the examiner's finger until it is nearly at midline. The right visual fields are intact. How
should the nurse score this item?
A. 0 – No visual loss
B. 1 – Partial hemianopia [CORRECT]
C. 2 – Complete hemianopia
D. 3 – Bilateral hemianopia or blindness
Correct Answer: B
NIHSS Domain: 3. Visual Fields
Score Range: 0–3
Rationale: [CORRECT] B (Score 1): The patient demonstrates partial left hemianopia —
some vision remains in the affected field (finger detected near midline) but is clearly
impaired. Complete hemianopia (Score 2) would show no detection in the affected
hemifield. A: Incorrect — visual field deficit is present. C: Incorrect — some vision
remains in the affected field. D: Incorrect — only one side affected. Common error:
Edition)
Complete Certification Exam Simulation – Verified Answers & Scoring
Rationales
APEX Innovations | NIH Stroke Scale International Certification Standards
Section 1: Patient 1 – Acute Ischemic Stroke, Right Hemisphere, Moderate
Deficits
Patient Profile: 68-year-old male, 4 hours post-symptom onset, alert but with left-sided
weakness and sensory changes.
Q1: Patient 1: Level of Consciousness (1a)
The examiner approaches the bed and observes the patient. The patient opens eyes
spontaneously when the examiner enters the room, is fully oriented to person, place,
and time, and engages in appropriate conversation. How should the nurse score this
item?
A. 0 – Alert; keenly responsive [CORRECT]
B. 1 – Not alert; but arousable with minor stimulation
C. 2 – Not alert; requires repeated stimulation
D. 3 – Coma; unresponsive or reflex responses only
Correct Answer: A
NIHSS Domain: 1a. Level of Consciousness
Score Range: 0–3
Rationale: [CORRECT] A (Score 0): The patient demonstrates all criteria for Score 0: eyes
open spontaneously, fully oriented, and appropriate interaction. No stimulation was
required to elicit attention. B (Score 1): Incorrect — patient does not require any
,stimulation to maintain alertness. C (Score 2): Incorrect — patient is not obtunded or
requiring repeated stimulation. D (Score 3): Incorrect — patient is clearly responsive and
interactive, not comatose. Common error: Scoring 1 because patient had stroke; NIHSS
LOC scoring is based on observed responsiveness, not diagnosis.
Q2: Patient 1: LOC Questions (1b)
The examiner asks: "What month is it?" The patient responds correctly. The examiner
asks: "How old are you?" The patient pauses, then states, "I'm... I'm not sure. Sixty...
something?" and cannot provide exact age. How should the nurse score this item?
A. 0 – Answers both questions correctly
B. 1 – Answers one question correctly [CORRECT]
C. 2 – Answers neither question correctly
D. Untestable (aphasic, intubated, etc.)
Correct Answer: B
NIHSS Domain: 1b. LOC Questions
Score Range: 0–2
Rationale: [CORRECT] B (Score 1): The patient answered the month correctly but failed
to provide correct age (even approximate decade is insufficient — exact age or close
approximation required). NIHSS allows credit for one correct answer only if both are
asked. A (Score 0): Incorrect — age was not answered correctly. C (Score 2): Incorrect —
one question was answered correctly. D: Incorrect — patient is able to respond verbally;
not untestable. Common error: Accepting "sixty-something" as correct; NIHSS requires
accurate age within 1-2 years or clear knowledge of one's age.
Q3: Patient 1: LOC Commands (1c)
The examiner instructs: "Open and close your eyes." The patient complies correctly. The
examiner then says: "Grip and release my hand." The patient looks confused, makes no
movement. The examiner repeats the command once. The patient slowly reaches out
,and grips with the right hand but does not release on command. How should the nurse
score this item?
A. 0 – Performs both tasks correctly
B. 1 – Performs one task correctly [CORRECT]
C. 2 – Performs neither task correctly
D. Untestable (amputation, trauma, etc.)
Correct Answer: B
NIHSS Domain: 1c. LOC Commands
Score Range: 0–2
Rationale: [CORRECT] B (Score 1): The eye command was performed correctly. The
grip/release command was not performed correctly — the patient required repetition,
used the wrong hand (right instead of left, which is paretic), and failed to release. Only
one task performed correctly = Score 1. A: Incorrect — grip/release was not correct. C:
Incorrect — eye task was correct. D: Incorrect — no physical barrier to testing. Common
error: Scoring 0 because patient "eventually" gripped; NIHSS requires correct performance
on first attempt after single repetition if needed.
Q4: Patient 1: Best Gaze (2)
The examiner asks the patient to follow a finger with eyes only, moving horizontally to
both sides. The patient's eyes follow to the right (toward the patient's right, examiner's
left) but do not cross midline when moving to the left. The examiner performs the
vertical gaze test — eyes move up and down normally. How should the nurse score this
item?
A. 0 – Normal
B. 1 – Partial gaze palsy; gaze 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 oculocephalic maneuver
D. Untestable
Correct Answer: B
, NIHSS Domain: 2. Best Gaze
Score Range: 0–2
Rationale: [CORRECT] B (Score 1): The patient demonstrates partial gaze palsy —
impaired gaze to the left (toward the side of the hemiparesis) but not forced deviation.
Eyes can be brought past midline with effort or reflex testing, but voluntary gaze is
impaired. Vertical gaze is intact. A: Incorrect — gaze abnormality is present. C: Incorrect
— forced deviation (Score 2) would show eyes fixed in one direction, not overcome by
voluntary effort or oculocephalic maneuver. D: Incorrect — patient is able to participate.
Common error: Scoring 0 because vertical gaze is normal; NIHSS horizontal gaze is the
primary assessment, and any abnormality = at least Score 1.
Q5: Patient 1: Visual Fields (3)
The examiner tests visual fields by confrontation. When testing the left visual field of
both eyes (temporal field of left eye, nasal field of right eye), the patient does not detect
the examiner's finger until it is nearly at midline. The right visual fields are intact. How
should the nurse score this item?
A. 0 – No visual loss
B. 1 – Partial hemianopia [CORRECT]
C. 2 – Complete hemianopia
D. 3 – Bilateral hemianopia or blindness
Correct Answer: B
NIHSS Domain: 3. Visual Fields
Score Range: 0–3
Rationale: [CORRECT] B (Score 1): The patient demonstrates partial left hemianopia —
some vision remains in the affected field (finger detected near midline) but is clearly
impaired. Complete hemianopia (Score 2) would show no detection in the affected
hemifield. A: Incorrect — visual field deficit is present. C: Incorrect — some vision
remains in the affected field. D: Incorrect — only one side affected. Common error:
