NIH STROKE SCALE (NIHSS) CERTIFICATION EXAM – QUESTIONS
AND ANSWERS | VERIFIED AND WELL DETAILED ANSWERS | PLUS
RATIONALES | A+ MATERIAL | NEWEST UPDATE
Core Domains
Level of Consciousness and Responsiveness
Gaze and Visual Field Assessment
Facial Palsy and Motor Function
Ataxia and Sensory Testing
Language, Dysarthria, and Extinction
Clinical Scoring Rules and Administration Protocols
IntroductionWelcome to the comprehensive assessment designed to
evaluate clinical proficiency for the NIH Stroke Scale Certification Exam.
The purpose of this rigorous examination is to ensure healthcare
professionals master the standardized scoring system vital for quantifying
acute stroke severity. Candidates will be assessed on foundational
neurological theory, advanced administration techniques, accurate item
scoring, and complex scenario-based interpretation. Emphasizing real-
world clinical application and rapid decision-making, the questions bridge
clinical theory with bedside practice. Utilizing a multi-format structure of
multiple-choice and complex patient scenarios, this material guarantees
optimal preparation for clinical trials, emergency neurological care, and
standardized stroke center protocols.
Question 1
When evaluating the Level of Consciousness (LOC) item on the NIHSS, a
patient is drowsy but arousable to minor stimulation to complete minor
commands. How should this item be scored?
A. 0
B. 1
C. 2
D. 3
🟢 B. 1
🔴 Explanation: A score of 1 is given if the patient is not alert, but
arousable by minor stimulation to obey, answer, or respond. A score of 0
represents alert, 2 represents obtunded, and 3 represents unresponsive.
Question 2
,During the LOC Questions portion, a patient with a severe aphasia and
right-sided hemiparesis incorrectly answers both the month and their age.
How should these responses be scored?
A. Score as incorrect because the answers are factually wrong.
B. Score as correct if the patient attempted to speak clearly.
C. Score as incorrect only if the patient refuses to answer.
D. Score as correct if the patient was confused due to medications.
🟢 A. Score as incorrect because the answers are factually wrong.
🔴 Explanation: Spoken answers are evaluated strictly for factual
accuracy. Aphasic or dysarthric patients who cannot articulate clearly are
still scored based on whether the intended, intelligible answer matches
reality.
Question 3
A patient is asked to open and close their eyes and then grip and release
non-paretic hand. If the patient has a severe hand amputation, how
should the examiner adapt the LOC Commands item?
A. Use an alternative one-step command such as wiggling toes.
B. Skip the motor command portion entirely and assign a default score.
C. Ask the patient to shrug their shoulders or open/close their mouth
instead.
D. Use a passive movement technique assisted by the nurse.
🟢 C. Ask the patient to shrug their shoulders or open/close their mouth
instead.
🔴 Explanation: If hands cannot be used due to amputation or trauma,
alternative one-step commands such as eye movements, shoulder
shrugs, or mouth opening should be substituted to test comprehension.
Question 4
When assessing Best Gaze (Item 2), what is the correct method for
testing horizontal eye movements in an alert patient?
A. The examiner must use reflexive optokinetic nystagmus tape.
B. The examiner uses voluntary tracking or the oculocephalic maneuver.
C. The examiner tests visual fields by finger wiggling in all four quadrants.
D. The examiner shines a bright penlight to check direct pupillary light
reflexes.
🟢 B. The examiner uses voluntary tracking or the oculocephalic
maneuver.
,🔴 Explanation: Horizontal eye movement is assessed by tracking the
examiner's finger or face. If the patient is unresponsive, ocular movement
can be tested using the oculocephalic (doll's eyes) reflex.
Question 5
A patient demonstrates complete left-sided conjugate deviation of the
eyes that cannot be overcome by voluntary effort or reflexive testing. How
is Best Gaze scored?
A. 0
B. 1
C. 2
D. 3
🟢 C. 2
🔴 Explanation: A score of 2 indicates forced deviation or total gaze
paresis that is not overcome by the oculocephalic maneuver. A score of 1
indicates partial gaze palsy, and 0 is normal.
Question 6
When testing Visual Fields (Item 3) using confrontation, how should the
examiner present targets to the patient?
A. Moving rapid fingers simultaneously in all four visual quadrants.
B. Counting fingers or wiggling fingers in upper and lower quadrants of
each eye.
C. Using high-contrast color cards held directly in the center of gaze.
D. Flashing a bright pocket flashlight across the nasal and temporal fields.
🟢 B. Counting fingers or wiggling fingers in upper and lower quadrants
of each eye.
🔴 Explanation: Visual fields are tested by confrontation using finger
counting or finger movement in upper and lower quadrants. Unilateral
blindness or complete hemianopia is scored based on findings.
Question 7
A patient with a right parietal stroke fails to acknowledge visual stimuli in
the left visual field when tested simultaneously, but sees them when
tested individually. What visual field score should be assigned?
A. 0
B. 1
, C. 2
D. 3
🟢 A. 0
🔴 Explanation: Visual extinction is captured under a separate item
(Inattention/Extinction). Item 3 (Visual Fields) scores actual field cuts, not
neglect or extinction, assuming single-stimulus testing is intact.
Question 8
A patient demonstrates flattening of the nasolabial fold and asymmetry
when asked to show teeth, but is able to close both eyes tightly against
resistance. What Facial Palsy score is appropriate?
A. 0
B. 1
C. 2
D. 3
🟢 B. 1
🔴 Explanation: A score of 1 indicates minor paralysis, such as flattening
of the nasolabial fold or asymmetry on smiling. Complete or near-
complete lower face paralysis scores higher.
Question 9
In a patient who is stuporous or unresponsive, how is the Facial Palsy
item evaluated?
A. By observing spontaneous facial grimace to painful noxious stimuli.
B. By checking deep tendon reflexes of the masseter muscle.
C. By inspecting the symmetry of spontaneous blink responses.
D. Facial palsy cannot be scored in obtunded patients.
🟢 A. By observing spontaneous facial grimace to painful noxious stimuli.
🔴 Explanation: In unresponsive patients, facial asymmetry is scored by
observing grimacing or facial movement elicited in response to noxious
stimuli (such as a sternal rub).
Question 10
When testing Motor Arm function (Items 5a and 5b), what is the correct
positioning angle for a patient sitting in a chair?
A. Arms extended at 45 degrees forward.
B. Arms extended at 90 degrees forward.
AND ANSWERS | VERIFIED AND WELL DETAILED ANSWERS | PLUS
RATIONALES | A+ MATERIAL | NEWEST UPDATE
Core Domains
Level of Consciousness and Responsiveness
Gaze and Visual Field Assessment
Facial Palsy and Motor Function
Ataxia and Sensory Testing
Language, Dysarthria, and Extinction
Clinical Scoring Rules and Administration Protocols
IntroductionWelcome to the comprehensive assessment designed to
evaluate clinical proficiency for the NIH Stroke Scale Certification Exam.
The purpose of this rigorous examination is to ensure healthcare
professionals master the standardized scoring system vital for quantifying
acute stroke severity. Candidates will be assessed on foundational
neurological theory, advanced administration techniques, accurate item
scoring, and complex scenario-based interpretation. Emphasizing real-
world clinical application and rapid decision-making, the questions bridge
clinical theory with bedside practice. Utilizing a multi-format structure of
multiple-choice and complex patient scenarios, this material guarantees
optimal preparation for clinical trials, emergency neurological care, and
standardized stroke center protocols.
Question 1
When evaluating the Level of Consciousness (LOC) item on the NIHSS, a
patient is drowsy but arousable to minor stimulation to complete minor
commands. How should this item be scored?
A. 0
B. 1
C. 2
D. 3
🟢 B. 1
🔴 Explanation: A score of 1 is given if the patient is not alert, but
arousable by minor stimulation to obey, answer, or respond. A score of 0
represents alert, 2 represents obtunded, and 3 represents unresponsive.
Question 2
,During the LOC Questions portion, a patient with a severe aphasia and
right-sided hemiparesis incorrectly answers both the month and their age.
How should these responses be scored?
A. Score as incorrect because the answers are factually wrong.
B. Score as correct if the patient attempted to speak clearly.
C. Score as incorrect only if the patient refuses to answer.
D. Score as correct if the patient was confused due to medications.
🟢 A. Score as incorrect because the answers are factually wrong.
🔴 Explanation: Spoken answers are evaluated strictly for factual
accuracy. Aphasic or dysarthric patients who cannot articulate clearly are
still scored based on whether the intended, intelligible answer matches
reality.
Question 3
A patient is asked to open and close their eyes and then grip and release
non-paretic hand. If the patient has a severe hand amputation, how
should the examiner adapt the LOC Commands item?
A. Use an alternative one-step command such as wiggling toes.
B. Skip the motor command portion entirely and assign a default score.
C. Ask the patient to shrug their shoulders or open/close their mouth
instead.
D. Use a passive movement technique assisted by the nurse.
🟢 C. Ask the patient to shrug their shoulders or open/close their mouth
instead.
🔴 Explanation: If hands cannot be used due to amputation or trauma,
alternative one-step commands such as eye movements, shoulder
shrugs, or mouth opening should be substituted to test comprehension.
Question 4
When assessing Best Gaze (Item 2), what is the correct method for
testing horizontal eye movements in an alert patient?
A. The examiner must use reflexive optokinetic nystagmus tape.
B. The examiner uses voluntary tracking or the oculocephalic maneuver.
C. The examiner tests visual fields by finger wiggling in all four quadrants.
D. The examiner shines a bright penlight to check direct pupillary light
reflexes.
🟢 B. The examiner uses voluntary tracking or the oculocephalic
maneuver.
,🔴 Explanation: Horizontal eye movement is assessed by tracking the
examiner's finger or face. If the patient is unresponsive, ocular movement
can be tested using the oculocephalic (doll's eyes) reflex.
Question 5
A patient demonstrates complete left-sided conjugate deviation of the
eyes that cannot be overcome by voluntary effort or reflexive testing. How
is Best Gaze scored?
A. 0
B. 1
C. 2
D. 3
🟢 C. 2
🔴 Explanation: A score of 2 indicates forced deviation or total gaze
paresis that is not overcome by the oculocephalic maneuver. A score of 1
indicates partial gaze palsy, and 0 is normal.
Question 6
When testing Visual Fields (Item 3) using confrontation, how should the
examiner present targets to the patient?
A. Moving rapid fingers simultaneously in all four visual quadrants.
B. Counting fingers or wiggling fingers in upper and lower quadrants of
each eye.
C. Using high-contrast color cards held directly in the center of gaze.
D. Flashing a bright pocket flashlight across the nasal and temporal fields.
🟢 B. Counting fingers or wiggling fingers in upper and lower quadrants
of each eye.
🔴 Explanation: Visual fields are tested by confrontation using finger
counting or finger movement in upper and lower quadrants. Unilateral
blindness or complete hemianopia is scored based on findings.
Question 7
A patient with a right parietal stroke fails to acknowledge visual stimuli in
the left visual field when tested simultaneously, but sees them when
tested individually. What visual field score should be assigned?
A. 0
B. 1
, C. 2
D. 3
🟢 A. 0
🔴 Explanation: Visual extinction is captured under a separate item
(Inattention/Extinction). Item 3 (Visual Fields) scores actual field cuts, not
neglect or extinction, assuming single-stimulus testing is intact.
Question 8
A patient demonstrates flattening of the nasolabial fold and asymmetry
when asked to show teeth, but is able to close both eyes tightly against
resistance. What Facial Palsy score is appropriate?
A. 0
B. 1
C. 2
D. 3
🟢 B. 1
🔴 Explanation: A score of 1 indicates minor paralysis, such as flattening
of the nasolabial fold or asymmetry on smiling. Complete or near-
complete lower face paralysis scores higher.
Question 9
In a patient who is stuporous or unresponsive, how is the Facial Palsy
item evaluated?
A. By observing spontaneous facial grimace to painful noxious stimuli.
B. By checking deep tendon reflexes of the masseter muscle.
C. By inspecting the symmetry of spontaneous blink responses.
D. Facial palsy cannot be scored in obtunded patients.
🟢 A. By observing spontaneous facial grimace to painful noxious stimuli.
🔴 Explanation: In unresponsive patients, facial asymmetry is scored by
observing grimacing or facial movement elicited in response to noxious
stimuli (such as a sternal rub).
Question 10
When testing Motor Arm function (Items 5a and 5b), what is the correct
positioning angle for a patient sitting in a chair?
A. Arms extended at 45 degrees forward.
B. Arms extended at 90 degrees forward.
