APEX INNOVATIONS | NIHSS CERTIFICATION AND RECERTIFICATION SERIES
APEX NIH Stroke Scale Group B
Patients 1-6 Study Guide and Practice Review
2026/2027 Updated | Aligned with Current NIHSS Certification Standards and the Standardized
NIHSS Scoring Protocol
Examination Metadata
APEX NIH Stroke Scale Group B - 6 complete patient scenarios, 66 individual item
Examination
scores (no more, no less)
Patients 1-6, each scored across all 11 NIHSS domains (Items 1a-11): acute left M1
occlusion with aphasia; right MCA infarct with neglect; left pontine posterior circulation
Patient case set
infarct; left capsular lacunar (pure motor) infarct; severe right M1 occlusion with
obtundation; left MCA inferior division fluent aphasia
4 options (A-D), exactly ONE correct NIHSS score per item; every option line carries a
Question format scored descriptor (0-4 scale for motor items, 0-3 for most others, UN where the protocol
applies)
Complete item-by-item scoring of 1a (alertness), 1b (month and age orientation), 1c
(open/close eyes and grip/release commands), 2 (best gaze), 3 (visual fields), 4 (facial
Scoring coverage palsy), 5a/5b (motor arm), 6a/6b (motor leg), 7 (limb ataxia), 8 (sensory), 9 (best
language), 10 (dysarthria), and 11 (extinction and inattention), with per-patient
answer-key totals and severity interpretation
30% recall (scoring definitions), 50% application (patient scenario scoring), 20%
Cognitive design
analysis (differentiating subtle neurological findings)
100% scenario-based patient assessments with verified scoring; distractors encode the
most common NIHSS scoring errors - confusing drift severity, misclassifying aphasia
versus dysarthria, missing subtle neglect, incorrect visual field grading, confusing gaze
Item style
preference versus partial gaze palsy versus forced deviation, misidentifying ataxia versus
weakness, inappropriate sensory grading, and failure to distinguish complete versus
incomplete paralysis
Drift criteria (no drift; drifts without hitting the bed; drifts down to the bed; no
movement), effort-against-gravity motor grading, extinction and bilateral simultaneous
Core emphases stimulation, menace testing in obtunded patients, coma versus stupor differentiation,
crossed brainstem findings, anatomical localization, total score interpretation (0-42), and
correlation of NIHSS scores with infarct volume and outcomes
2026/2027 edition aligned with the current AHA/ASA standardized NIHSS protocol and
Currency APEX Innovations Group B case methodology, including time-sensitive documentation
with repeat NIHSS every 15 minutes during and after thrombolysis
NIHSS Examination Blueprint - All 11 Domains x 6 Patients
APEX NIH Stroke Scale Group B - Patients 1-6 Study Guide and Practice Review 1
,APEX NIH Stroke Scale Group B - 2026/2027 Updated Standards 66 Item Scores - 6 Patient Scenarios
Item Domain Range What the Item Assesses (Standardized Criteria)
Response to stimulation: alert, not alert but arousable, requires repeated
1a LOC - Alertness 0-3
stimulation, coma/unresponsive
Month and age; aphasic or stuporous patients who do not comprehend the
1b LOC - Orientation 0-2
questions score 2
Open/close eyes and grip/release the non-paretic hand; pantomime or
1c LOC - Commands 0-2
demonstration substituted when commands fail
Horizontal eye movement; partial palsy (can cross midline) versus forced
2 Best Gaze 0-2
deviation or total paresis not overcome by oculocephalic testing
Upper and lower quadrants of each eye; extinction on double simultaneous
3 Visual Fields 0-3
stimulation scores 1; menace/blink testing when commands fail
Grimace, show teeth, raise eyebrows; minor versus partial (lower half) versus
4 Facial Palsy 0-3
complete (upper and lower face) paralysis
10-second hold at 45 degrees (seated): no drift; drifts without hitting the bed;
5a/5b Motor Arm (L/R) 0-4 each
some effort against gravity, drifts to bed; no effort, falls; no movement
5-second hold at 30 degrees: no drift; drifts, falls by end of interval; some
6a/6b Motor Leg (L/R) 0-4 each
effort against gravity, drifts to bed; no effort, falls immediately; no movement
Finger-to-nose and heel-to-shin; scored only when out of proportion to
7 Limb Ataxia 0-2
weakness; 0 if comatose or paralyzed; one limb versus two limbs
Pinprick over face, arms, hands, legs, trunk; mild-moderate (less sharp) versus
8 Sensory 0-3
severe-total (no awareness, pressure response) versus no response
Naming, repetition, fluency, comprehension; severity graded by information
9 Best Language 0-3
exchanged, not by fluency - fluent jargon can score 2
Speech articulation clarity judged at worst performance; UN only for
10 Dysarthria 0-2
intubation or physical barrier; never scored from language content
Neglect on bilateral simultaneous stimulation (visual, tactile, auditory, spatial,
11 Extinction/Inattention 0-2 personal); one modality versus more than one modality or own-hand
non-recognition
Severity bands: 0 no stroke symptoms; 1-4 minor; 5-15 moderate; 15-20
Total All items 0-42 moderate-to-severe; 21-42 severe; higher totals correlate with larger infarct
volumes and worse 90-day outcomes
How to Use This Study Guide and Practice Review
• Score each of the 66 items for the six Group B patients before reading the keyed solution; every question has exactly
one best answer among options A-D, and the correct letter is confirmed on the Correct Answer line.
• The keyed option is marked [CORRECT] on the option line; each rationale (2-3 sentences) explains why the keyed
score is correct and why each distractor encodes a common scoring error, citing the specific standardized criterion,
examination technique, and clinical significance.
• Patients appear in ascending severity and subtlety range typical of APEX Group B: dominant-hemisphere weakness
with aphasia (Q1-11), nondominant neglect (Q12-22), posterior circulation brainstem findings (Q23-33), pure motor
lacune (Q34-44), severe obtunded presentation (Q45-55), and fluent aphasia without weakness (Q56-66).
APEX NIH Stroke Scale Group B - Patients 1-6 Study Guide and Practice Review 2
, APEX NIH Stroke Scale Group B - 2026/2027 Updated Standards 66 Item Scores - 6 Patient Scenarios
• Per-patient answer-key totals and severity bands appear in each patient header and in the rationale of that patient's
final item; item ranges are Q1-11, Q12-22, Q23-33, Q34-44, Q45-55, and Q56-66, covering all 11 NIHSS domains
once per patient.
APEX NIH Stroke Scale Group B - Patients 1-6 Study Guide and Practice Review 3
APEX NIH Stroke Scale Group B
Patients 1-6 Study Guide and Practice Review
2026/2027 Updated | Aligned with Current NIHSS Certification Standards and the Standardized
NIHSS Scoring Protocol
Examination Metadata
APEX NIH Stroke Scale Group B - 6 complete patient scenarios, 66 individual item
Examination
scores (no more, no less)
Patients 1-6, each scored across all 11 NIHSS domains (Items 1a-11): acute left M1
occlusion with aphasia; right MCA infarct with neglect; left pontine posterior circulation
Patient case set
infarct; left capsular lacunar (pure motor) infarct; severe right M1 occlusion with
obtundation; left MCA inferior division fluent aphasia
4 options (A-D), exactly ONE correct NIHSS score per item; every option line carries a
Question format scored descriptor (0-4 scale for motor items, 0-3 for most others, UN where the protocol
applies)
Complete item-by-item scoring of 1a (alertness), 1b (month and age orientation), 1c
(open/close eyes and grip/release commands), 2 (best gaze), 3 (visual fields), 4 (facial
Scoring coverage palsy), 5a/5b (motor arm), 6a/6b (motor leg), 7 (limb ataxia), 8 (sensory), 9 (best
language), 10 (dysarthria), and 11 (extinction and inattention), with per-patient
answer-key totals and severity interpretation
30% recall (scoring definitions), 50% application (patient scenario scoring), 20%
Cognitive design
analysis (differentiating subtle neurological findings)
100% scenario-based patient assessments with verified scoring; distractors encode the
most common NIHSS scoring errors - confusing drift severity, misclassifying aphasia
versus dysarthria, missing subtle neglect, incorrect visual field grading, confusing gaze
Item style
preference versus partial gaze palsy versus forced deviation, misidentifying ataxia versus
weakness, inappropriate sensory grading, and failure to distinguish complete versus
incomplete paralysis
Drift criteria (no drift; drifts without hitting the bed; drifts down to the bed; no
movement), effort-against-gravity motor grading, extinction and bilateral simultaneous
Core emphases stimulation, menace testing in obtunded patients, coma versus stupor differentiation,
crossed brainstem findings, anatomical localization, total score interpretation (0-42), and
correlation of NIHSS scores with infarct volume and outcomes
2026/2027 edition aligned with the current AHA/ASA standardized NIHSS protocol and
Currency APEX Innovations Group B case methodology, including time-sensitive documentation
with repeat NIHSS every 15 minutes during and after thrombolysis
NIHSS Examination Blueprint - All 11 Domains x 6 Patients
APEX NIH Stroke Scale Group B - Patients 1-6 Study Guide and Practice Review 1
,APEX NIH Stroke Scale Group B - 2026/2027 Updated Standards 66 Item Scores - 6 Patient Scenarios
Item Domain Range What the Item Assesses (Standardized Criteria)
Response to stimulation: alert, not alert but arousable, requires repeated
1a LOC - Alertness 0-3
stimulation, coma/unresponsive
Month and age; aphasic or stuporous patients who do not comprehend the
1b LOC - Orientation 0-2
questions score 2
Open/close eyes and grip/release the non-paretic hand; pantomime or
1c LOC - Commands 0-2
demonstration substituted when commands fail
Horizontal eye movement; partial palsy (can cross midline) versus forced
2 Best Gaze 0-2
deviation or total paresis not overcome by oculocephalic testing
Upper and lower quadrants of each eye; extinction on double simultaneous
3 Visual Fields 0-3
stimulation scores 1; menace/blink testing when commands fail
Grimace, show teeth, raise eyebrows; minor versus partial (lower half) versus
4 Facial Palsy 0-3
complete (upper and lower face) paralysis
10-second hold at 45 degrees (seated): no drift; drifts without hitting the bed;
5a/5b Motor Arm (L/R) 0-4 each
some effort against gravity, drifts to bed; no effort, falls; no movement
5-second hold at 30 degrees: no drift; drifts, falls by end of interval; some
6a/6b Motor Leg (L/R) 0-4 each
effort against gravity, drifts to bed; no effort, falls immediately; no movement
Finger-to-nose and heel-to-shin; scored only when out of proportion to
7 Limb Ataxia 0-2
weakness; 0 if comatose or paralyzed; one limb versus two limbs
Pinprick over face, arms, hands, legs, trunk; mild-moderate (less sharp) versus
8 Sensory 0-3
severe-total (no awareness, pressure response) versus no response
Naming, repetition, fluency, comprehension; severity graded by information
9 Best Language 0-3
exchanged, not by fluency - fluent jargon can score 2
Speech articulation clarity judged at worst performance; UN only for
10 Dysarthria 0-2
intubation or physical barrier; never scored from language content
Neglect on bilateral simultaneous stimulation (visual, tactile, auditory, spatial,
11 Extinction/Inattention 0-2 personal); one modality versus more than one modality or own-hand
non-recognition
Severity bands: 0 no stroke symptoms; 1-4 minor; 5-15 moderate; 15-20
Total All items 0-42 moderate-to-severe; 21-42 severe; higher totals correlate with larger infarct
volumes and worse 90-day outcomes
How to Use This Study Guide and Practice Review
• Score each of the 66 items for the six Group B patients before reading the keyed solution; every question has exactly
one best answer among options A-D, and the correct letter is confirmed on the Correct Answer line.
• The keyed option is marked [CORRECT] on the option line; each rationale (2-3 sentences) explains why the keyed
score is correct and why each distractor encodes a common scoring error, citing the specific standardized criterion,
examination technique, and clinical significance.
• Patients appear in ascending severity and subtlety range typical of APEX Group B: dominant-hemisphere weakness
with aphasia (Q1-11), nondominant neglect (Q12-22), posterior circulation brainstem findings (Q23-33), pure motor
lacune (Q34-44), severe obtunded presentation (Q45-55), and fluent aphasia without weakness (Q56-66).
APEX NIH Stroke Scale Group B - Patients 1-6 Study Guide and Practice Review 2
, APEX NIH Stroke Scale Group B - 2026/2027 Updated Standards 66 Item Scores - 6 Patient Scenarios
• Per-patient answer-key totals and severity bands appear in each patient header and in the rationale of that patient's
final item; item ranges are Q1-11, Q12-22, Q23-33, Q34-44, Q45-55, and Q56-66, covering all 11 NIHSS domains
once per patient.
APEX NIH Stroke Scale Group B - Patients 1-6 Study Guide and Practice Review 3
