, NIH STROKE SCALE (NIHSS) GROUP A -
PRACTICE EXAM MULTIPLE CHOICE QUESTIONS
WITH ANSWERS AND ITALICIZED RATIONALES
130 QUESTIONS
TABLE OF CONTENTS
# TOPIC
1 Accurately score all NIHSS items in nuanced and atypical presentations
2 Identify pitfalls and common errors in NIHSS administration
3 Apply NIHSS in clinical decision-making and research contexts
4 Critically evaluate the scale's psychometric properties and limitations
5 NIH Stroke Scale
6 NIHSS
7 Group A
8 Practice Exam Multiple Choice Questions with Answers and Italicized Rationales
9 Foundations of Neurology / Stroke Assessment
10 Applied Neurology / Stroke Assessment
11 Advanced Neurology / Stroke Assessment
12 Neurology / Stroke Assessment Review
Page 1
,Q1 ACCURATELY SCORE ALL NIHSS ITEMS IN NUANCED AND ATYPICAL PRESENTATIONS
A patient with a left hemispheric stroke is asked to perform the level of
consciousness commands. The patient has severe aphasia and cannot understand
any spoken language, but follows the examiner's gestures to close eyes and make
a fist. How should the examiner score item 1c (commands)?
A. Score 0 because the patient performed both tasks correctly CORRECT
B. Score 1 because the patient required non-verbal cues
C. Score 2 because the patient is unable to comprehend language
D. Score 0 only if the patient repeats the commands correctly
RATIONALE: The NIHSS allows the use of pantomime or gestures to convey the commands if
the patient is aphasic; if the patient performs both tasks correctly, the score is 0. A score of 1 is
for partial performance, and 2 is for no response. The patient's inability to understand language is
compensated by non-verbal instruction.
Q2 ACCURATELY SCORE ALL NIHSS ITEMS IN NUANCED AND ATYPICAL PRESENTATIONS
Which of the following best describes the 'dominant hemisphere' determination for
scoring the NIHSS item on best language?
A. The hemisphere contralateral to the patient's handedness
B. The hemisphere ipsilateral to the patient's handedness
C. The left hemisphere in all right-handed patients and most left-handed patients CORRECT
D. The hemisphere that shows the most severe hypoperfusion on imaging
RATIONALE: The NIHSS assumes left hemisphere dominance for language in the vast majority
of patients, including most left-handed individuals. Handedness is not a reliable sole indicator,
and imaging is not used for this determination. Thus, the language item is scored based on the
left hemisphere unless there is clear evidence of right hemisphere dominance.
Page 2
, Q3 ACCURATELY SCORE ALL NIHSS ITEMS IN NUANCED AND ATYPICAL PRESENTATIONS
A patient with a right middle cerebral artery stroke presents with left-sided visual
neglect. When asked to identify the number of fingers shown in both visual fields,
the patient only reports fingers on the right side. How should the examiner score
item 3 (visual fields)?
A. Score 1 because the patient has partial hemianopia
B. Score 2 because the patient has complete hemianopia
C. Score 1 because the patient has extinction to bilateral simultaneous stimulation CORRECT
D. Score 0 because the patient can see fingers on the right side
RATIONALE: Visual extinction, where the patient fails to perceive stimuli on the affected side
only during bilateral simultaneous stimulation, is scored as 1 on the NIHSS. A score of 2 is for
complete hemianopia, and 0 is for no visual loss. The scenario describes extinction, not a
complete field cut.
Q4 ACCURATELY SCORE ALL NIHSS ITEMS IN NUANCED AND ATYPICAL PRESENTATIONS
In a patient with a brainstem stroke, which of the following findings would be most
likely to produce a falsely low NIHSS score?
A. Isolated diplopia and nystagmus CORRECT
B. Severe dysarthria with mild facial weakness
C. Complete gaze palsy with no other deficits
D. Hemisensory loss on the face, arm, and leg
RATIONALE: The NIHSS has poor sensitivity for posterior circulation deficits, particularly isolated
diplopia, nystagmus, and vertigo, which are not assessed by the scale. Dysarthria, gaze palsy,
and sensory loss are captured to some extent. Thus, a brainstem stroke presenting with isolated
diplopia would yield a low score despite significant disability.
Page 3
PRACTICE EXAM MULTIPLE CHOICE QUESTIONS
WITH ANSWERS AND ITALICIZED RATIONALES
130 QUESTIONS
TABLE OF CONTENTS
# TOPIC
1 Accurately score all NIHSS items in nuanced and atypical presentations
2 Identify pitfalls and common errors in NIHSS administration
3 Apply NIHSS in clinical decision-making and research contexts
4 Critically evaluate the scale's psychometric properties and limitations
5 NIH Stroke Scale
6 NIHSS
7 Group A
8 Practice Exam Multiple Choice Questions with Answers and Italicized Rationales
9 Foundations of Neurology / Stroke Assessment
10 Applied Neurology / Stroke Assessment
11 Advanced Neurology / Stroke Assessment
12 Neurology / Stroke Assessment Review
Page 1
,Q1 ACCURATELY SCORE ALL NIHSS ITEMS IN NUANCED AND ATYPICAL PRESENTATIONS
A patient with a left hemispheric stroke is asked to perform the level of
consciousness commands. The patient has severe aphasia and cannot understand
any spoken language, but follows the examiner's gestures to close eyes and make
a fist. How should the examiner score item 1c (commands)?
A. Score 0 because the patient performed both tasks correctly CORRECT
B. Score 1 because the patient required non-verbal cues
C. Score 2 because the patient is unable to comprehend language
D. Score 0 only if the patient repeats the commands correctly
RATIONALE: The NIHSS allows the use of pantomime or gestures to convey the commands if
the patient is aphasic; if the patient performs both tasks correctly, the score is 0. A score of 1 is
for partial performance, and 2 is for no response. The patient's inability to understand language is
compensated by non-verbal instruction.
Q2 ACCURATELY SCORE ALL NIHSS ITEMS IN NUANCED AND ATYPICAL PRESENTATIONS
Which of the following best describes the 'dominant hemisphere' determination for
scoring the NIHSS item on best language?
A. The hemisphere contralateral to the patient's handedness
B. The hemisphere ipsilateral to the patient's handedness
C. The left hemisphere in all right-handed patients and most left-handed patients CORRECT
D. The hemisphere that shows the most severe hypoperfusion on imaging
RATIONALE: The NIHSS assumes left hemisphere dominance for language in the vast majority
of patients, including most left-handed individuals. Handedness is not a reliable sole indicator,
and imaging is not used for this determination. Thus, the language item is scored based on the
left hemisphere unless there is clear evidence of right hemisphere dominance.
Page 2
, Q3 ACCURATELY SCORE ALL NIHSS ITEMS IN NUANCED AND ATYPICAL PRESENTATIONS
A patient with a right middle cerebral artery stroke presents with left-sided visual
neglect. When asked to identify the number of fingers shown in both visual fields,
the patient only reports fingers on the right side. How should the examiner score
item 3 (visual fields)?
A. Score 1 because the patient has partial hemianopia
B. Score 2 because the patient has complete hemianopia
C. Score 1 because the patient has extinction to bilateral simultaneous stimulation CORRECT
D. Score 0 because the patient can see fingers on the right side
RATIONALE: Visual extinction, where the patient fails to perceive stimuli on the affected side
only during bilateral simultaneous stimulation, is scored as 1 on the NIHSS. A score of 2 is for
complete hemianopia, and 0 is for no visual loss. The scenario describes extinction, not a
complete field cut.
Q4 ACCURATELY SCORE ALL NIHSS ITEMS IN NUANCED AND ATYPICAL PRESENTATIONS
In a patient with a brainstem stroke, which of the following findings would be most
likely to produce a falsely low NIHSS score?
A. Isolated diplopia and nystagmus CORRECT
B. Severe dysarthria with mild facial weakness
C. Complete gaze palsy with no other deficits
D. Hemisensory loss on the face, arm, and leg
RATIONALE: The NIHSS has poor sensitivity for posterior circulation deficits, particularly isolated
diplopia, nystagmus, and vertigo, which are not assessed by the scale. Dysarthria, gaze palsy,
and sensory loss are captured to some extent. Thus, a brainstem stroke presenting with isolated
diplopia would yield a low score despite significant disability.
Page 3
