NIHSS Group C - Patients 1-6 Complete Answer key **2026/2027** — 2026/2027 Official Exam
OBJECTIVE ASSESSMENT - EXAM
NIHSS Group C - Patients 1-6 Complete Answer
key **2026/2027** — 2026/2027 Official Exam
75 100% 2026/2027
QUESTIONS VERIFIED ANSWERS EDITION
TOPICS COVERED
NIHSS Administration & Scoring Visual & Sensory Evaluation
Level of Consciousness & Orientation Coordination & Language Testing
Motor Function Assessment Patient Scenarios 1-6 Analysis
COVER PAGE - 1
, SECTION 1 | NIHSS Administration and Scoring | Q1-Q13 | NIHSS Group C - Patients 1-6 Complete Answer key **2026/2027** — 2026/2027 Official Exam
S1 2026/2027
Q1 Question 1 of 75
A nurse certified in NIHSS administration is preparing to assess a 72-year-old patient with acute right
hemiparesis. The patient arrives 90 minutes after symptom onset. Which principle guides the timing and serial
administration of the NIHSS in acute stroke?
A. The NIHSS is performed only once at admission and never repeated during hospitalization.
B. The NIHSS should be performed initially at presentation, repeated at intervals to track neurologic
change, and used to guide thrombolytic eligibility and prognosis.
C. The NIHSS cannot be administered within the first 24 hours of symptom onset.
D. The NIHSS is performed only after thrombolytic administration to assess response.
Correct Answer: B
Rationale:
The NIHSS is administered at baseline, then serially to track neurologic changes, guide thrombolytic decisions, and predict
outcomes. Performing it only once misses clinical changes; it can be administered at any time after onset; and baseline scoring
before thrombolysis is essential.
Q2 Question 2 of 75
An examiner completes an NIHSS assessment on a 68-year-old stroke patient and records a total score of 16.
Based on standard NIHSS severity classification, this score is best categorized as which level of stroke severity?
A. Mild stroke, as scores 1 to 4 indicate mild deficit.
B. Slight stroke, as scores 5 to 15 indicate slight deficit.
C. Moderate to severe stroke, as scores 15 to 20 indicate moderate to severe neurologic deficit with
significant functional impact.
D. Severe stroke, as scores 21 to 42 indicate severe deficit.
Correct Answer: C
Rationale:
NIHSS severity: 0 no stroke, 1 to 4 minor, 5 to 15 moderate, 16 to 20 moderate to severe, 21 to 42 severe. A score of 16 falls in the
moderate to severe category. The other options misclassify the score into incorrect severity bands.
NIHSS Group C - Patients 1-6 Complete Answer key **2026/2027** — 2026/2027 Official Exam — 2026/2027 | Passing Score: 80% Page 2 of 35
, Q3 Question 3 of 75
A clinician is training a new nurse on NIHSS administration. The trainee asks how to score an item when the
patient cannot complete the task due to amputation or physical limitation unrelated to stroke. Which instruction is
most accurate?
A. Assign a score of 0 to all untestable items to avoid inflating the total.
B. Assign the maximum score to untestable items to capture worst-case deficit.
C. Skip untestable items entirely and reduce the maximum total score accordingly.
D. Score the item as untestable (UN) and document the reason, as amputations or physical limitations
preclude valid scoring of that item.
Correct Answer: D
Rationale:
Items that cannot be performed due to amputation, orthopedic limitation, or other non-stroke causes are documented as untestable
(UN) with the reason; they are not scored numerically. Scoring 0 inflates false normalcy; scoring maximum inflates false deficit;
skipping alters the total scale.
Q4 Question 4 of 75
A nurse administers the NIHSS to a 75-year-old patient with right hemisphere stroke who has left visual field loss
and left neglect. When scoring visual fields, the nurse uses visual threat to assess the affected field. Which visual
field score should be assigned if the patient does not blink to threat in the left hemifield but tracks normally on the
right?
A. Score 2 for complete hemianopia, since the patient shows no response to visual threat in the left
hemifield.
B. Score 1 for partial hemianopia, since some vision may be preserved.
C. Score 0 for no visual loss, since the right field is intact.
D. Score 3 for bilateral hemianopia including blindness.
Correct Answer: A
Rationale:
Complete loss of response to visual threat in one hemifield corresponds to score 2 (complete hemianopia). Score 1 is partial
hemianopia; score 0 is no visual loss; score 3 is bilateral hemianopia or blindness. Visual threat is used when formal
confrontational testing cannot be performed.
NIHSS Group C - Patients 1-6 Complete Answer key **2026/2027** — 2026/2027 Official Exam — 2026/2027 | Passing Score: 80% Page 3 of 35
, Q5 Question 5 of 75
During NIHSS training, a clinician is asked about the maximum total score possible on the standard 15-item scale.
Which value is correct?
A. 31 points maximum across all items, indicating only mild deficit at the upper end.
B. 42 points maximum across the 15 standard items, with higher scores indicating greater neurologic
deficit.
C. 20 points maximum, with anything above 15 considered off-scale.
D. 100 points maximum, similar to other neurologic rating scales.
Correct Answer: B
Rationale:
The standard NIHSS has 15 items with a maximum total score of 42 points; higher scores indicate more severe neurologic deficit.
The scale is not 31, 20, or 100 points; those values misrepresent the structure of the NIHSS.
Q6 Question 6 of 75
A nurse is preparing to administer the NIHSS to an intubated and sedated patient in the ICU. Which approach is
most appropriate for scoring items requiring verbal response?
A. Assign a verbal score of 0 since the patient cannot speak.
B. Assign the maximum verbal score since intubation implies severe impairment.
C. Score verbal items as untestable (UN) due to intubation, and document that intubation precludes valid
verbal assessment.
D. Extubate the patient temporarily to perform the verbal assessment.
Correct Answer: C
Rationale:
Intubated patients cannot be validly assessed for verbal items; these are scored as untestable (UN) with documentation of
intubation. Assigning 0 falsely normalizes; maximum inflates deficit; temporary extubation is unsafe and inappropriate for NIHSS
assessment.
NIHSS Group C - Patients 1-6 Complete Answer key **2026/2027** — 2026/2027 Official Exam — 2026/2027 | Passing Score: 80% Page 4 of 35
OBJECTIVE ASSESSMENT - EXAM
NIHSS Group C - Patients 1-6 Complete Answer
key **2026/2027** — 2026/2027 Official Exam
75 100% 2026/2027
QUESTIONS VERIFIED ANSWERS EDITION
TOPICS COVERED
NIHSS Administration & Scoring Visual & Sensory Evaluation
Level of Consciousness & Orientation Coordination & Language Testing
Motor Function Assessment Patient Scenarios 1-6 Analysis
COVER PAGE - 1
, SECTION 1 | NIHSS Administration and Scoring | Q1-Q13 | NIHSS Group C - Patients 1-6 Complete Answer key **2026/2027** — 2026/2027 Official Exam
S1 2026/2027
Q1 Question 1 of 75
A nurse certified in NIHSS administration is preparing to assess a 72-year-old patient with acute right
hemiparesis. The patient arrives 90 minutes after symptom onset. Which principle guides the timing and serial
administration of the NIHSS in acute stroke?
A. The NIHSS is performed only once at admission and never repeated during hospitalization.
B. The NIHSS should be performed initially at presentation, repeated at intervals to track neurologic
change, and used to guide thrombolytic eligibility and prognosis.
C. The NIHSS cannot be administered within the first 24 hours of symptom onset.
D. The NIHSS is performed only after thrombolytic administration to assess response.
Correct Answer: B
Rationale:
The NIHSS is administered at baseline, then serially to track neurologic changes, guide thrombolytic decisions, and predict
outcomes. Performing it only once misses clinical changes; it can be administered at any time after onset; and baseline scoring
before thrombolysis is essential.
Q2 Question 2 of 75
An examiner completes an NIHSS assessment on a 68-year-old stroke patient and records a total score of 16.
Based on standard NIHSS severity classification, this score is best categorized as which level of stroke severity?
A. Mild stroke, as scores 1 to 4 indicate mild deficit.
B. Slight stroke, as scores 5 to 15 indicate slight deficit.
C. Moderate to severe stroke, as scores 15 to 20 indicate moderate to severe neurologic deficit with
significant functional impact.
D. Severe stroke, as scores 21 to 42 indicate severe deficit.
Correct Answer: C
Rationale:
NIHSS severity: 0 no stroke, 1 to 4 minor, 5 to 15 moderate, 16 to 20 moderate to severe, 21 to 42 severe. A score of 16 falls in the
moderate to severe category. The other options misclassify the score into incorrect severity bands.
NIHSS Group C - Patients 1-6 Complete Answer key **2026/2027** — 2026/2027 Official Exam — 2026/2027 | Passing Score: 80% Page 2 of 35
, Q3 Question 3 of 75
A clinician is training a new nurse on NIHSS administration. The trainee asks how to score an item when the
patient cannot complete the task due to amputation or physical limitation unrelated to stroke. Which instruction is
most accurate?
A. Assign a score of 0 to all untestable items to avoid inflating the total.
B. Assign the maximum score to untestable items to capture worst-case deficit.
C. Skip untestable items entirely and reduce the maximum total score accordingly.
D. Score the item as untestable (UN) and document the reason, as amputations or physical limitations
preclude valid scoring of that item.
Correct Answer: D
Rationale:
Items that cannot be performed due to amputation, orthopedic limitation, or other non-stroke causes are documented as untestable
(UN) with the reason; they are not scored numerically. Scoring 0 inflates false normalcy; scoring maximum inflates false deficit;
skipping alters the total scale.
Q4 Question 4 of 75
A nurse administers the NIHSS to a 75-year-old patient with right hemisphere stroke who has left visual field loss
and left neglect. When scoring visual fields, the nurse uses visual threat to assess the affected field. Which visual
field score should be assigned if the patient does not blink to threat in the left hemifield but tracks normally on the
right?
A. Score 2 for complete hemianopia, since the patient shows no response to visual threat in the left
hemifield.
B. Score 1 for partial hemianopia, since some vision may be preserved.
C. Score 0 for no visual loss, since the right field is intact.
D. Score 3 for bilateral hemianopia including blindness.
Correct Answer: A
Rationale:
Complete loss of response to visual threat in one hemifield corresponds to score 2 (complete hemianopia). Score 1 is partial
hemianopia; score 0 is no visual loss; score 3 is bilateral hemianopia or blindness. Visual threat is used when formal
confrontational testing cannot be performed.
NIHSS Group C - Patients 1-6 Complete Answer key **2026/2027** — 2026/2027 Official Exam — 2026/2027 | Passing Score: 80% Page 3 of 35
, Q5 Question 5 of 75
During NIHSS training, a clinician is asked about the maximum total score possible on the standard 15-item scale.
Which value is correct?
A. 31 points maximum across all items, indicating only mild deficit at the upper end.
B. 42 points maximum across the 15 standard items, with higher scores indicating greater neurologic
deficit.
C. 20 points maximum, with anything above 15 considered off-scale.
D. 100 points maximum, similar to other neurologic rating scales.
Correct Answer: B
Rationale:
The standard NIHSS has 15 items with a maximum total score of 42 points; higher scores indicate more severe neurologic deficit.
The scale is not 31, 20, or 100 points; those values misrepresent the structure of the NIHSS.
Q6 Question 6 of 75
A nurse is preparing to administer the NIHSS to an intubated and sedated patient in the ICU. Which approach is
most appropriate for scoring items requiring verbal response?
A. Assign a verbal score of 0 since the patient cannot speak.
B. Assign the maximum verbal score since intubation implies severe impairment.
C. Score verbal items as untestable (UN) due to intubation, and document that intubation precludes valid
verbal assessment.
D. Extubate the patient temporarily to perform the verbal assessment.
Correct Answer: C
Rationale:
Intubated patients cannot be validly assessed for verbal items; these are scored as untestable (UN) with documentation of
intubation. Assigning 0 falsely normalizes; maximum inflates deficit; temporary extubation is unsafe and inappropriate for NIHSS
assessment.
NIHSS Group C - Patients 1-6 Complete Answer key **2026/2027** — 2026/2027 Official Exam — 2026/2027 | Passing Score: 80% Page 4 of 35
