APEX NIH Stroke Scale - Group A - Patients 1-6 - 2026/2027 NIHSS Certification Study Guide
APEX NIH Stroke Scale - Group A
APEX Innovations - NIHSS Certification & Recertification
Patients 1-6 Study Guide and Practice Review - 2026/2027
Exam Format: 66 multiple-choice questions organized into 6 complete NIH Stroke Scale (NIHSS) patient assessments
(Items 1a through 11 per patient). Each item is scored per the 2026/2027 standardized NIHSS protocol. Cognitive
distribution: 30% recall of scoring definitions, 50% application of scoring to clinical scenarios, 20% analysis differentiating
subtle neurological findings. Each question presents four scoring options (A-D) with one best answer per NIHSS criteria.
Scoring ranges span 0-4 depending on the item, with specific drift criteria (no drift, drifts without hitting bed, drifts to hit bed,
no movement) for motor items. Total possible NIHSS score range is 0-42. Each answer includes a detailed rationale citing the
NIHSS standardized examination protocol and clinical significance for stroke localization and severity.
Patient 1 - Acute Right MCA Territory Infarct - 67-year-old Female
Vignette: A 67-year-old female arrives 90 minutes after sudden onset of left-sided weakness and slurred speech. She is
awake, follows commands, but has left facial droop, left arm and leg weakness, and slurred speech. CT shows no
hemorrhage. NIHSS scoring is performed per APEX Group A standardized protocol.
Q1. Patient 1 - NIHSS Item 1a: Level of Consciousness - The patient is a 67-year-old female who is awake, makes
eye contact, and responds immediately when you enter the room. She is fully alert and responsive to your
questions without needing any stimulation. What is the correct score for Item 1a?
A. 0 - Alert; keenly responsive [CORRECT]
B. 1 - Not alert, but arousable by minor stimulation
C. 2 - Not alert; requires repeated stimulation to attend
D. 3 - Responds only with reflex motor or unresponsive
Correct Answer: A
Rationale: Item 1a scores alertness: a patient who is awake, making eye contact, and immediately responsive scores 0 (Alert).
Scores 1-3 are reserved for patients who are drowsy, require repeated stimulation, or are unresponsive. This patient has normal
alertness, so the only correct score is 0.
Q2. Patient 1 - NIHSS Item 1b: LOC Questions - When asked, the patient correctly states her age (67) but states
the month is "October" when it is actually March. She is asked both month and age at admission. What is the
correct score for Item 1b?
A. 0 - Answers both questions correctly
B. 1 - Answers one question correctly [CORRECT]
C. 2 - Answers neither question correctly
D. 3 - Intubated or unable to speak
Correct Answer: B
Rationale: Item 1b asks the patient to state the current month and their age. The patient answered age correctly but the month
incorrectly, scoring 1 (one correct answer). Score 0 requires both correct; score 2 requires both wrong. Score 3 is reserved for
intubated/aphasic patients who cannot respond.
APEX Innovations - NIHSS Certification/Recertification Page 1
,APEX NIH Stroke Scale - Group A - Patients 1-6 - 2026/2027 NIHSS Certification Study Guide
Q3. Patient 1 - NIHSS Item 1c: LOC Commands - The patient is asked to "open and close your eyes" and "grip
and release your hand." She successfully opens and closes both eyes and grips with her right hand and releases.
She attempts to grip with her left (affected) hand but cannot generate a visible grip. What is the correct score for
Item 1c?
A. 0 - Performs both tasks correctly [CORRECT]
B. 1 - Performs one task correctly
C. 2 - Performs neither task correctly
D. 3 - Coma or unresponsive
Correct Answer: A
Rationale: Item 1c scores the ability to follow two commands (open/close eyes, grip/release hand). The patient performs both
tasks correctly - the eyes task is fully successful, and the grip task only requires ONE hand to grip and release successfully.
Hemiparesis preventing grip in the affected hand does not reduce the score if the unaffected hand performs the task. Score 0 is
correct.
Q4. Patient 1 - NIHSS Item 2: Best Gaze - The patient is asked to look left and right. She is able to move her eyes
horizontally in both directions without difficulty and follows the examiner's finger fully to both sides. There is no
gaze preference or palsy. What is the correct score for Item 2?
A. 0 - Normal horizontal movement [CORRECT]
B. 1 - Partial gaze palsy; gaze abnormal in one or both eyes, but forced deviation or total paresis is not present
C. 2 - Forced deviation, or total gaze paresis not overcome by the oculocephalic maneuver
D. 1 - Forced deviation that cannot be overcome by oculocephalic maneuver
Correct Answer: A
Rationale: Item 2 scores horizontal eye movement. Normal horizontal movement in both directions scores 0. Score 1 is partial
gaze palsy with limited range but preserved movement. Score 2 is forced deviation or total gaze paresis. This patient has normal
gaze, so score 0 is correct. Option D is invalid NIHSS coding - score 1 is partial, not forced deviation.
Q5. Patient 1 - NIHSS Item 3: Visual Fields - Visual field testing by confrontation shows the patient has a left
homonymous hemianopia affecting the upper and lower quadrants of the left visual field in both eyes. The right
visual field is fully intact and she correctly identifies finger movement on the right side. What is the correct score
for Item 3?
A. 0 - No visual loss
B. 1 - Partial hemianopia (e.g., quadrantanopia, partial hemianopia)
C. 2 - Complete hemianopia [CORRECT]
D. 3 - Bilateral hemianopia or blindness
Correct Answer: C
Rationale: Item 3 scoring: 0 = no loss; 1 = partial hemianopia or quadrantanopia; 2 = complete hemianopia of one side; 3 =
bilateral. The patient has a complete left homonymous hemianopia affecting both upper and lower quadrants of the left field in
both eyes, which is a complete hemianopia scoring 2. Score 1 would apply to quadrantanopia or partial field loss; score 3
requires bilateral blindness.
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, APEX NIH Stroke Scale - Group A - Patients 1-6 - 2026/2027 NIHSS Certification Study Guide
Q6. Patient 1 - NIHSS Item 4: Facial Palsy - The patient is asked to show teeth, raise eyebrows, and squeeze eyes
shut. There is noticeable flattening of the left nasolabial fold and drooping of the left corner of the mouth. The
forehead and eye closure are symmetric and preserved. What is the correct score for Item 4?
A. 0 - Normal symmetrical movement
B. 1 - Minor paralysis (flattened nasolabial fold, slight asymmetry on smile) [CORRECT]
C. 2 - Partial paralysis (total or near-total paralysis of lower face)
D. 3 - Complete paralysis of one or both sides
Correct Answer: B
Rationale: Item 4 scoring: 0 = normal; 1 = minor paralysis (flattened nasolabial fold, slight smile asymmetry); 2 = partial
(lower face near-total paralysis with forehead sparing, typical of UMN lesions); 3 = complete unilateral or bilateral. Flattened
nasolabial fold with mouth droop and preserved forehead = score 1, classic for mild-to-moderate UMN facial weakness in
stroke.
Q7. Patient 1 - NIHSS Item 5a: Motor Arm - Left (Affected) - The patient is asked to hold her left arm
outstretched (90 degrees, supinated) for 10 seconds. The left arm drifts downward within 5 seconds but does not
hit the bed. She cannot sustain the position. What is the correct score for Item 5a?
A. 0 - No drift; arm holds 90 (or 45) degrees for full 10 seconds
B. 1 - Drift; arm drifts down but does not hit bed or support [CORRECT]
C. 2 - Some effort against gravity; arm drifts down to hit bed or support
D. 3 - No effort against gravity; arm falls immediately
Correct Answer: B
Rationale: Item 5a motor arm scoring: 0 = holds 10 seconds; 1 = drifts but does not hit bed; 2 = drifts down to hit bed; 3 = no
effort against gravity (falls immediately). The left arm drifts but does not hit the bed within 10 seconds, scoring 1. Drift indicates
mild paresis with preserved antigravity strength.
Q8. Patient 1 - NIHSS Item 5b: Motor Arm - Right (Unaffected) - The patient is asked to hold her right arm
outstretched (90 degrees) for 10 seconds. The right arm holds steady for the full 10 seconds without any drift.
What is the correct score for Item 5b?
A. 0 - No drift; arm holds 90 (or 45) degrees for full 10 seconds [CORRECT]
B. 1 - Drift; arm drifts down but does not hit bed or support
C. 2 - Some effort against gravity; arm drifts down to hit bed
D. 3 - No effort against gravity
Correct Answer: A
Rationale: The right (unaffected) arm holds steady at 90 degrees for the full 10 seconds without drift, scoring 0. Item 5b is scored
independently from 5a using the same criteria; the unaffected side in this right MCA infarct has normal motor function, so score
0 is correct.
APEX Innovations - NIHSS Certification/Recertification Page 3
APEX NIH Stroke Scale - Group A
APEX Innovations - NIHSS Certification & Recertification
Patients 1-6 Study Guide and Practice Review - 2026/2027
Exam Format: 66 multiple-choice questions organized into 6 complete NIH Stroke Scale (NIHSS) patient assessments
(Items 1a through 11 per patient). Each item is scored per the 2026/2027 standardized NIHSS protocol. Cognitive
distribution: 30% recall of scoring definitions, 50% application of scoring to clinical scenarios, 20% analysis differentiating
subtle neurological findings. Each question presents four scoring options (A-D) with one best answer per NIHSS criteria.
Scoring ranges span 0-4 depending on the item, with specific drift criteria (no drift, drifts without hitting bed, drifts to hit bed,
no movement) for motor items. Total possible NIHSS score range is 0-42. Each answer includes a detailed rationale citing the
NIHSS standardized examination protocol and clinical significance for stroke localization and severity.
Patient 1 - Acute Right MCA Territory Infarct - 67-year-old Female
Vignette: A 67-year-old female arrives 90 minutes after sudden onset of left-sided weakness and slurred speech. She is
awake, follows commands, but has left facial droop, left arm and leg weakness, and slurred speech. CT shows no
hemorrhage. NIHSS scoring is performed per APEX Group A standardized protocol.
Q1. Patient 1 - NIHSS Item 1a: Level of Consciousness - The patient is a 67-year-old female who is awake, makes
eye contact, and responds immediately when you enter the room. She is fully alert and responsive to your
questions without needing any stimulation. What is the correct score for Item 1a?
A. 0 - Alert; keenly responsive [CORRECT]
B. 1 - Not alert, but arousable by minor stimulation
C. 2 - Not alert; requires repeated stimulation to attend
D. 3 - Responds only with reflex motor or unresponsive
Correct Answer: A
Rationale: Item 1a scores alertness: a patient who is awake, making eye contact, and immediately responsive scores 0 (Alert).
Scores 1-3 are reserved for patients who are drowsy, require repeated stimulation, or are unresponsive. This patient has normal
alertness, so the only correct score is 0.
Q2. Patient 1 - NIHSS Item 1b: LOC Questions - When asked, the patient correctly states her age (67) but states
the month is "October" when it is actually March. She is asked both month and age at admission. What is the
correct score for Item 1b?
A. 0 - Answers both questions correctly
B. 1 - Answers one question correctly [CORRECT]
C. 2 - Answers neither question correctly
D. 3 - Intubated or unable to speak
Correct Answer: B
Rationale: Item 1b asks the patient to state the current month and their age. The patient answered age correctly but the month
incorrectly, scoring 1 (one correct answer). Score 0 requires both correct; score 2 requires both wrong. Score 3 is reserved for
intubated/aphasic patients who cannot respond.
APEX Innovations - NIHSS Certification/Recertification Page 1
,APEX NIH Stroke Scale - Group A - Patients 1-6 - 2026/2027 NIHSS Certification Study Guide
Q3. Patient 1 - NIHSS Item 1c: LOC Commands - The patient is asked to "open and close your eyes" and "grip
and release your hand." She successfully opens and closes both eyes and grips with her right hand and releases.
She attempts to grip with her left (affected) hand but cannot generate a visible grip. What is the correct score for
Item 1c?
A. 0 - Performs both tasks correctly [CORRECT]
B. 1 - Performs one task correctly
C. 2 - Performs neither task correctly
D. 3 - Coma or unresponsive
Correct Answer: A
Rationale: Item 1c scores the ability to follow two commands (open/close eyes, grip/release hand). The patient performs both
tasks correctly - the eyes task is fully successful, and the grip task only requires ONE hand to grip and release successfully.
Hemiparesis preventing grip in the affected hand does not reduce the score if the unaffected hand performs the task. Score 0 is
correct.
Q4. Patient 1 - NIHSS Item 2: Best Gaze - The patient is asked to look left and right. She is able to move her eyes
horizontally in both directions without difficulty and follows the examiner's finger fully to both sides. There is no
gaze preference or palsy. What is the correct score for Item 2?
A. 0 - Normal horizontal movement [CORRECT]
B. 1 - Partial gaze palsy; gaze abnormal in one or both eyes, but forced deviation or total paresis is not present
C. 2 - Forced deviation, or total gaze paresis not overcome by the oculocephalic maneuver
D. 1 - Forced deviation that cannot be overcome by oculocephalic maneuver
Correct Answer: A
Rationale: Item 2 scores horizontal eye movement. Normal horizontal movement in both directions scores 0. Score 1 is partial
gaze palsy with limited range but preserved movement. Score 2 is forced deviation or total gaze paresis. This patient has normal
gaze, so score 0 is correct. Option D is invalid NIHSS coding - score 1 is partial, not forced deviation.
Q5. Patient 1 - NIHSS Item 3: Visual Fields - Visual field testing by confrontation shows the patient has a left
homonymous hemianopia affecting the upper and lower quadrants of the left visual field in both eyes. The right
visual field is fully intact and she correctly identifies finger movement on the right side. What is the correct score
for Item 3?
A. 0 - No visual loss
B. 1 - Partial hemianopia (e.g., quadrantanopia, partial hemianopia)
C. 2 - Complete hemianopia [CORRECT]
D. 3 - Bilateral hemianopia or blindness
Correct Answer: C
Rationale: Item 3 scoring: 0 = no loss; 1 = partial hemianopia or quadrantanopia; 2 = complete hemianopia of one side; 3 =
bilateral. The patient has a complete left homonymous hemianopia affecting both upper and lower quadrants of the left field in
both eyes, which is a complete hemianopia scoring 2. Score 1 would apply to quadrantanopia or partial field loss; score 3
requires bilateral blindness.
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, APEX NIH Stroke Scale - Group A - Patients 1-6 - 2026/2027 NIHSS Certification Study Guide
Q6. Patient 1 - NIHSS Item 4: Facial Palsy - The patient is asked to show teeth, raise eyebrows, and squeeze eyes
shut. There is noticeable flattening of the left nasolabial fold and drooping of the left corner of the mouth. The
forehead and eye closure are symmetric and preserved. What is the correct score for Item 4?
A. 0 - Normal symmetrical movement
B. 1 - Minor paralysis (flattened nasolabial fold, slight asymmetry on smile) [CORRECT]
C. 2 - Partial paralysis (total or near-total paralysis of lower face)
D. 3 - Complete paralysis of one or both sides
Correct Answer: B
Rationale: Item 4 scoring: 0 = normal; 1 = minor paralysis (flattened nasolabial fold, slight smile asymmetry); 2 = partial
(lower face near-total paralysis with forehead sparing, typical of UMN lesions); 3 = complete unilateral or bilateral. Flattened
nasolabial fold with mouth droop and preserved forehead = score 1, classic for mild-to-moderate UMN facial weakness in
stroke.
Q7. Patient 1 - NIHSS Item 5a: Motor Arm - Left (Affected) - The patient is asked to hold her left arm
outstretched (90 degrees, supinated) for 10 seconds. The left arm drifts downward within 5 seconds but does not
hit the bed. She cannot sustain the position. What is the correct score for Item 5a?
A. 0 - No drift; arm holds 90 (or 45) degrees for full 10 seconds
B. 1 - Drift; arm drifts down but does not hit bed or support [CORRECT]
C. 2 - Some effort against gravity; arm drifts down to hit bed or support
D. 3 - No effort against gravity; arm falls immediately
Correct Answer: B
Rationale: Item 5a motor arm scoring: 0 = holds 10 seconds; 1 = drifts but does not hit bed; 2 = drifts down to hit bed; 3 = no
effort against gravity (falls immediately). The left arm drifts but does not hit the bed within 10 seconds, scoring 1. Drift indicates
mild paresis with preserved antigravity strength.
Q8. Patient 1 - NIHSS Item 5b: Motor Arm - Right (Unaffected) - The patient is asked to hold her right arm
outstretched (90 degrees) for 10 seconds. The right arm holds steady for the full 10 seconds without any drift.
What is the correct score for Item 5b?
A. 0 - No drift; arm holds 90 (or 45) degrees for full 10 seconds [CORRECT]
B. 1 - Drift; arm drifts down but does not hit bed or support
C. 2 - Some effort against gravity; arm drifts down to hit bed
D. 3 - No effort against gravity
Correct Answer: A
Rationale: The right (unaffected) arm holds steady at 90 degrees for the full 10 seconds without drift, scoring 0. Item 5b is scored
independently from 5a using the same criteria; the unaffected side in this right MCA infarct has normal motor function, so score
0 is correct.
APEX Innovations - NIHSS Certification/Recertification Page 3
