NIH Stroke Scale (NIHSS) Group A — Practice
Exam 200 Multiple Choice Questions with
Answers and Italicized Rationales.
Section 1: NIHSS Fundamentals & Administration Principles
Q1. The National Institutes of Health Stroke Scale (NIHSS) is primarily used to:
A. Diagnose the specific type of stroke
B. Quantify the severity of neurological deficit in acute stroke patients and serially
monitor changes over time
C. Determine the exact location of a cerebral infarction
D. Replace brain imaging in stroke evaluation
Rationale: The NIHSS is a standardized, quantifiable neurological examination tool. It
measures stroke severity, guides treatment decisions (including tPA eligibility), and tracks
improvement or deterioration. It does not replace imaging or determine stroke etiology.
Q2. The NIHSS assesses how many distinct neurological domains?
A. 5 items with a maximum score of 20
B. 11 items with a total possible score ranging from 0 (no deficit) to 42 (severe stroke)
C. 15 items with a maximum score of 50
D. 8 items with a maximum score of 25
,Rationale: The NIHSS evaluates 11 items: Level of Consciousness (1A, 1B, 1C), Best Gaze,
Visual Fields, Facial Palsy, Motor Arm (left and right), Motor Leg (left and right), Limb
Ataxia, Sensory, Best Language, Dysarthria, and Extinction/Inattention. Scores range from
0-42.
Q3. When administering the NIHSS, the examiner should:
A. Accept the patient's first response without encouraging best effort
B. Score the patient's first effort, but items generally should be scored based on what
the patient actually does, not what the examiner thinks the patient can do
C. Always provide maximum assistance to help the patient achieve the best score
D. Skip items the patient finds difficult
Rationale: The NIHSS is scored based on the patient's actual performance. The examiner
should not coach or assist beyond the standardized instructions. If the patient does not
respond, they are scored based on that lack of response (e.g., scoring untestable items as
appropriate).
Q4. The NIHSS should be administered in the following order:
A. Any order the examiner prefers
B. Strictly in the order presented on the scale (1A through 11), as the sequence is
designed for efficiency and consistency
C. From the most severe to least severe items
D. Starting with motor function first
Rationale: Standardized administration order ensures reliability across examiners. The
sequence flows logically: consciousness, gaze, vision, face, motor, coordination, sensory,
language, speech, and neglect.
,Q5. A score of 0 on the NIHSS indicates:
A. The patient is deceased
B. No measurable neurological deficit in the domains assessed
C. The patient has a mild stroke that requires no treatment
D. The examination was not completed
Rationale: A score of 0 indicates no stroke-related deficits detected by the NIHSS. However,
the NIHSS may not capture all deficits (e.g., posterior circulation strokes, subtle cognitive
changes), so a score of 0 does not definitively rule out stroke.
Q6. The maximum possible NIHSS score is 42. A patient with a score of 25-42 is
generally classified as having:
A. A minor stroke
B. A moderate stroke
C. A severe to very severe stroke, often with significant disability and higher mortality
risk
D. No stroke at all
Rationale: NIHSS severity categories are generally: 0 (no stroke symptoms), 1-4 (minor
stroke), 5-15 (moderate stroke), 16-20 (moderate to severe stroke), 21-42 (severe stroke).
Higher scores correlate with larger infarcts and worse outcomes.
Q7. The NIHSS is most reliable when administered by:
A. Any healthcare professional without training
B. Certified examiners who have completed standardized training and demonstrated
, competency through video-based certification
C. Only neurologists
D. Family members of the patient
Rationale: Standardized training and certification ensure inter-rater reliability. NIHSS
certification involves viewing and scoring patient videos, with results compared to expert
consensus scores. Recertification is typically required periodically.
Q8. When a patient is unable to cooperate with a specific NIHSS item due to coma,
intubation, or language barrier, the item should be:
A. Skipped entirely
B. Scored based on standardized rules for untestable items; the examiner documents the
reason and scores accordingly
C. Given a score of 0 to avoid penalizing the patient
D. Estimated based on the examiner's clinical judgment alone
Rationale: The NIHSS includes specific scoring rules for untestable items. For example, an
intubated patient may be scored based on writing or other non-verbal responses.
Comatose patients typically score high on affected items.
Q9. The NIHSS was originally developed as a research tool for:
A. Diagnosing myocardial infarction
B. Measuring baseline stroke severity in clinical trials of acute stroke therapies,
particularly thrombolytics
C. Screening for dementia
D. Evaluating traumatic brain injury
Exam 200 Multiple Choice Questions with
Answers and Italicized Rationales.
Section 1: NIHSS Fundamentals & Administration Principles
Q1. The National Institutes of Health Stroke Scale (NIHSS) is primarily used to:
A. Diagnose the specific type of stroke
B. Quantify the severity of neurological deficit in acute stroke patients and serially
monitor changes over time
C. Determine the exact location of a cerebral infarction
D. Replace brain imaging in stroke evaluation
Rationale: The NIHSS is a standardized, quantifiable neurological examination tool. It
measures stroke severity, guides treatment decisions (including tPA eligibility), and tracks
improvement or deterioration. It does not replace imaging or determine stroke etiology.
Q2. The NIHSS assesses how many distinct neurological domains?
A. 5 items with a maximum score of 20
B. 11 items with a total possible score ranging from 0 (no deficit) to 42 (severe stroke)
C. 15 items with a maximum score of 50
D. 8 items with a maximum score of 25
,Rationale: The NIHSS evaluates 11 items: Level of Consciousness (1A, 1B, 1C), Best Gaze,
Visual Fields, Facial Palsy, Motor Arm (left and right), Motor Leg (left and right), Limb
Ataxia, Sensory, Best Language, Dysarthria, and Extinction/Inattention. Scores range from
0-42.
Q3. When administering the NIHSS, the examiner should:
A. Accept the patient's first response without encouraging best effort
B. Score the patient's first effort, but items generally should be scored based on what
the patient actually does, not what the examiner thinks the patient can do
C. Always provide maximum assistance to help the patient achieve the best score
D. Skip items the patient finds difficult
Rationale: The NIHSS is scored based on the patient's actual performance. The examiner
should not coach or assist beyond the standardized instructions. If the patient does not
respond, they are scored based on that lack of response (e.g., scoring untestable items as
appropriate).
Q4. The NIHSS should be administered in the following order:
A. Any order the examiner prefers
B. Strictly in the order presented on the scale (1A through 11), as the sequence is
designed for efficiency and consistency
C. From the most severe to least severe items
D. Starting with motor function first
Rationale: Standardized administration order ensures reliability across examiners. The
sequence flows logically: consciousness, gaze, vision, face, motor, coordination, sensory,
language, speech, and neglect.
,Q5. A score of 0 on the NIHSS indicates:
A. The patient is deceased
B. No measurable neurological deficit in the domains assessed
C. The patient has a mild stroke that requires no treatment
D. The examination was not completed
Rationale: A score of 0 indicates no stroke-related deficits detected by the NIHSS. However,
the NIHSS may not capture all deficits (e.g., posterior circulation strokes, subtle cognitive
changes), so a score of 0 does not definitively rule out stroke.
Q6. The maximum possible NIHSS score is 42. A patient with a score of 25-42 is
generally classified as having:
A. A minor stroke
B. A moderate stroke
C. A severe to very severe stroke, often with significant disability and higher mortality
risk
D. No stroke at all
Rationale: NIHSS severity categories are generally: 0 (no stroke symptoms), 1-4 (minor
stroke), 5-15 (moderate stroke), 16-20 (moderate to severe stroke), 21-42 (severe stroke).
Higher scores correlate with larger infarcts and worse outcomes.
Q7. The NIHSS is most reliable when administered by:
A. Any healthcare professional without training
B. Certified examiners who have completed standardized training and demonstrated
, competency through video-based certification
C. Only neurologists
D. Family members of the patient
Rationale: Standardized training and certification ensure inter-rater reliability. NIHSS
certification involves viewing and scoring patient videos, with results compared to expert
consensus scores. Recertification is typically required periodically.
Q8. When a patient is unable to cooperate with a specific NIHSS item due to coma,
intubation, or language barrier, the item should be:
A. Skipped entirely
B. Scored based on standardized rules for untestable items; the examiner documents the
reason and scores accordingly
C. Given a score of 0 to avoid penalizing the patient
D. Estimated based on the examiner's clinical judgment alone
Rationale: The NIHSS includes specific scoring rules for untestable items. For example, an
intubated patient may be scored based on writing or other non-verbal responses.
Comatose patients typically score high on affected items.
Q9. The NIHSS was originally developed as a research tool for:
A. Diagnosing myocardial infarction
B. Measuring baseline stroke severity in clinical trials of acute stroke therapies,
particularly thrombolytics
C. Screening for dementia
D. Evaluating traumatic brain injury
