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NIH Stroke Scale (NIHSS) Group E Test – Latest Updated Comprehensive
Study Guide and Practice Examination (PDF Format)
NIH Stroke Scale (NIHSS) Group E Test – Comprehensive Study Guide and Practice
Examination
Summarized Exam Coverage
This examination comprehensively covers all 11 components of the NIH Stroke Scale including
level of consciousness (questions 1a, 1b, 1c), best gaze (item 2), visual fields (item 3), facial
palsy (item 4), motor arm and motor leg (items 5a, 5b, 6a, 6b), limb ataxia (item 7), sensory
(item 8), best language (item 9), dysarthria (item 10), and extinction and inattention (item 11).
The test emphasizes accurate scoring based on patient responses, physical examination findings,
and clinical scenarios that reflect real-world stroke assessment situations. Each question
requires understanding of specific scoring criteria, subtle neurological deficits, and the ability to
differentiate between normal and abnormal findings across all scale components. The
examination also covers important nuances such as the difference between visual field deficits
and extinction, language assessment techniques, and proper motor function testing procedures
including the use of the 90-degree arm position and 30-degree leg elevation. Additionally, the
content addresses common pitfalls in scoring, including when to use untestable scores, how to
handle intubated or aphasic patients, and the significance of specific scores in predicting stroke
outcomes. The exam incorporates both straightforward scoring scenarios and complex clinical
presentations that require integration of multiple neurological findings to determine accurate
total scores.
Multiple Choice Questions
1. A 68-year-old right-handed male presents with acute onset of right-sided weakness and is unable to follow commands.
During the NIHSS assessment, the patient is confused and unable to answer questions about his age or the current month.
What score should be assigned to item 1b?
A) 0 - Alert and fully oriented
B) 1 - Answers both questions correctly
C) 2 - Answers one question correctly
D) 3 - Answers neither question correctly
The patient cannot answer either question about his age or the current month, indicating severe impairment in orientation and
level of consciousness. Item 1b specifically evaluates the patient's ability to answer these two standard questions, and failure to
answer either correctly warrants a score of 3, which indicates a significant alteration in consciousness that affects basic
orientation.
2. A 72-year-old female with a history of hypertension presents with left-sided weakness. During the NIHSS examination,
she is able to follow commands but cannot state her age correctly, though she correctly identifies the current month. What
score is appropriate for item 1b?
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A) 0 - Answers both correctly
B) 1 - Answers one correctly
C) 2 - Answers neither correctly
D) 3 - Cannot answer due to intubation
The patient correctly identifies the current month but fails to provide her correct age, demonstrating partial orientation
impairment. Since she answers one of the two questions correctly, a score of 1 is assigned, which indicates mild impairment in
orientation without complete disorientation or confusion that would warrant a higher score.
3. During the assessment of item 1c, a patient is able to open and close their eyes on command but cannot grasp and
release their non-affected hand. The patient appears to understand the command but is physically unable to perform the
second task. What is the correct score for this item?
A) 0 - Performs both tasks correctly
B) 1 - Performs one task correctly
C) 2 - Performs neither task correctly
D) 3 - Unable to assess due to motor deficit
The patient successfully performs the eye-opening component but fails to execute the hand-grasping task despite understanding
the command. Since item 1c requires both tasks to be performed correctly for a score of 0, and the patient fails one task, they
receive a score of 2, which indicates an inability to follow commands related to the non-affected side motor function.
4. A patient with acute stroke has conjugate deviation of the eyes to the left when examined during the NIHSS assessment.
What score should be documented for item 2?
A) 0 - Normal gaze
B) 1 - Partial gaze palsy
C) 2 - Forced deviation or total gaze paresis
D) 3 - Unable to assess due to ocular abnormality
Conjugate deviation of the eyes indicates a complete gaze palsy toward the side of the brain lesion, which is scored as 2 on item
2 because it represents forced deviation that cannot be overcome by voluntary or reflex eye movements. This finding typically
suggests a large hemispheric or brainstem stroke and carries significant prognostic implications for patient outcomes.
5. A 65-year-old patient presents with right homonymous hemianopia on visual field testing using the confrontation
method with finger counting. The patient can see the examiner's fingers on the left side but consistently fails to see them
on the right side. What is the appropriate score for item 3?
A) 0 - No visual loss
B) 1 - Partial hemianopia
C) 2 - Complete hemianopia
D) 3 - Bilateral hemianopia
The patient demonstrates a right homonymous hemianopia with preservation of visual fields on the left side, which is scored as 1
on item 3 because it indicates a partial visual field defect. This finding represents involvement of the optic radiation or visual
cortex on the contralateral side and requires careful documentation to guide further diagnostic evaluation.
6. During the NIHSS assessment, a patient shows flattening of the left nasolabial fold and inability to raise the left
eyebrow symmetrically. However, when asked to show teeth, the patient has full symmetric movement on both sides.
What score should be given for facial palsy?
A) 0 - Normal symmetric movement
B) 1 - Minor paralysis (flattened nasolabial fold)
NIH Stroke Scale (NIHSS) Group E Test – Latest Updated Comprehensive
Study Guide and Practice Examination (PDF Format)
NIH Stroke Scale (NIHSS) Group E Test – Comprehensive Study Guide and Practice
Examination
Summarized Exam Coverage
This examination comprehensively covers all 11 components of the NIH Stroke Scale including
level of consciousness (questions 1a, 1b, 1c), best gaze (item 2), visual fields (item 3), facial
palsy (item 4), motor arm and motor leg (items 5a, 5b, 6a, 6b), limb ataxia (item 7), sensory
(item 8), best language (item 9), dysarthria (item 10), and extinction and inattention (item 11).
The test emphasizes accurate scoring based on patient responses, physical examination findings,
and clinical scenarios that reflect real-world stroke assessment situations. Each question
requires understanding of specific scoring criteria, subtle neurological deficits, and the ability to
differentiate between normal and abnormal findings across all scale components. The
examination also covers important nuances such as the difference between visual field deficits
and extinction, language assessment techniques, and proper motor function testing procedures
including the use of the 90-degree arm position and 30-degree leg elevation. Additionally, the
content addresses common pitfalls in scoring, including when to use untestable scores, how to
handle intubated or aphasic patients, and the significance of specific scores in predicting stroke
outcomes. The exam incorporates both straightforward scoring scenarios and complex clinical
presentations that require integration of multiple neurological findings to determine accurate
total scores.
Multiple Choice Questions
1. A 68-year-old right-handed male presents with acute onset of right-sided weakness and is unable to follow commands.
During the NIHSS assessment, the patient is confused and unable to answer questions about his age or the current month.
What score should be assigned to item 1b?
A) 0 - Alert and fully oriented
B) 1 - Answers both questions correctly
C) 2 - Answers one question correctly
D) 3 - Answers neither question correctly
The patient cannot answer either question about his age or the current month, indicating severe impairment in orientation and
level of consciousness. Item 1b specifically evaluates the patient's ability to answer these two standard questions, and failure to
answer either correctly warrants a score of 3, which indicates a significant alteration in consciousness that affects basic
orientation.
2. A 72-year-old female with a history of hypertension presents with left-sided weakness. During the NIHSS examination,
she is able to follow commands but cannot state her age correctly, though she correctly identifies the current month. What
score is appropriate for item 1b?
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A) 0 - Answers both correctly
B) 1 - Answers one correctly
C) 2 - Answers neither correctly
D) 3 - Cannot answer due to intubation
The patient correctly identifies the current month but fails to provide her correct age, demonstrating partial orientation
impairment. Since she answers one of the two questions correctly, a score of 1 is assigned, which indicates mild impairment in
orientation without complete disorientation or confusion that would warrant a higher score.
3. During the assessment of item 1c, a patient is able to open and close their eyes on command but cannot grasp and
release their non-affected hand. The patient appears to understand the command but is physically unable to perform the
second task. What is the correct score for this item?
A) 0 - Performs both tasks correctly
B) 1 - Performs one task correctly
C) 2 - Performs neither task correctly
D) 3 - Unable to assess due to motor deficit
The patient successfully performs the eye-opening component but fails to execute the hand-grasping task despite understanding
the command. Since item 1c requires both tasks to be performed correctly for a score of 0, and the patient fails one task, they
receive a score of 2, which indicates an inability to follow commands related to the non-affected side motor function.
4. A patient with acute stroke has conjugate deviation of the eyes to the left when examined during the NIHSS assessment.
What score should be documented for item 2?
A) 0 - Normal gaze
B) 1 - Partial gaze palsy
C) 2 - Forced deviation or total gaze paresis
D) 3 - Unable to assess due to ocular abnormality
Conjugate deviation of the eyes indicates a complete gaze palsy toward the side of the brain lesion, which is scored as 2 on item
2 because it represents forced deviation that cannot be overcome by voluntary or reflex eye movements. This finding typically
suggests a large hemispheric or brainstem stroke and carries significant prognostic implications for patient outcomes.
5. A 65-year-old patient presents with right homonymous hemianopia on visual field testing using the confrontation
method with finger counting. The patient can see the examiner's fingers on the left side but consistently fails to see them
on the right side. What is the appropriate score for item 3?
A) 0 - No visual loss
B) 1 - Partial hemianopia
C) 2 - Complete hemianopia
D) 3 - Bilateral hemianopia
The patient demonstrates a right homonymous hemianopia with preservation of visual fields on the left side, which is scored as 1
on item 3 because it indicates a partial visual field defect. This finding represents involvement of the optic radiation or visual
cortex on the contralateral side and requires careful documentation to guide further diagnostic evaluation.
6. During the NIHSS assessment, a patient shows flattening of the left nasolabial fold and inability to raise the left
eyebrow symmetrically. However, when asked to show teeth, the patient has full symmetric movement on both sides.
What score should be given for facial palsy?
A) 0 - Normal symmetric movement
B) 1 - Minor paralysis (flattened nasolabial fold)
