NIH Stroke Scale Test Groups A–F Patients 1–6-
Certified Scoring Guide & Clinical Training Materials
[Graded A+]
This definitive clinical reference guide contains the complete set of all National Institutes
of Health Stroke Scale (NIHSS) Test Groups A through F, covering patient case
scenarios 1 through 6. It provides updated clinical training metrics, official scoring
criteria, and differential diagnosis rationales for evaluating acute neurological deficits,
including gaze, visual fields, motor function, ataxia, sensory loss, and language.
Healthcare practitioners, emergency nurses, and neurologists will master the standard
physical assessment protocols required to eliminate scoring variability and successfully
pass their official certification track.
1. Which of the following is the correct action if a patient cannot follow
commands due to a language barrier rather than aphasia?
A. Score Item 1c as 2
B. Use a translator or pantomime to assess command following
C. Skip Item 1c and document as not assessed
D. Score Item 1c as 1
Answer: B. Use a translator or pantomime to assess command following
Rationale: The NIHSS should be administered in the patient's preferred language or with
an interpreter. If a language barrier exists, pantomime and demonstration should be used
before scoring. A score of 2 is only for true inability to follow commands due to
neurological deficit, not language barrier.
2. During assessment of Item 7 (Limb Ataxia), which of the following tests is used
for the upper extremities?
A. Heel-to-shin test
B. Finger-to-nose test
,C. Rapid alternating movements
D. Pronator drift
Answer: B. Finger-to-nose test
Rationale: Item 7 uses the finger-to-nose test for the arms and the heel-to-shin test for the
legs. Ataxia is scored based on the presence of cerebellar-type incoordination.
3. A patient is comatose. How should Item 8 (Sensory) be scored?
A. 0
B. 1
C. 2
D. Not assessed
Answer: C. 2
Rationale: If the patient is comatose or unresponsive, sensory function cannot be reliably
assessed, and Item 8 is scored 2 (severe to total sensory loss).
4. Which of the following is true regarding the administration of Item 1a (Level of
Consciousness)?
A. The examiner should use painful stimulation first
B. The examiner should observe for spontaneous responses before stimulation
C. The examiner should shake the patient vigorously
D. The examiner should only assess verbal responses
Answer: B. The examiner should observe for spontaneous responses before
stimulation
Rationale: Item 1a begins with observation. If the patient is alert and responsive
spontaneously, score 0. If not, the examiner progresses to verbal then painful stimulation.
,5. A patient has a score of 2 on Item 2 (Best Gaze). What is the most likely finding?
A. Normal gaze
B. Partial gaze palsy overcome by oculocephalic reflex
C. Forced deviation not overcome by voluntary or reflexive activity
D. Bilateral gaze palsy
Answer: C. Forced deviation not overcome by voluntary or reflexive activity
Rationale: Item 2 scores 2 for forced deviation that is not overcome by voluntary or
reflexive activity (e.g., oculocephalic maneuver).
6. Which of the following statements about Item 9 (Best Language) is correct?
A. The examiner should only assess spontaneous speech
B. The examiner should use a standardized picture description task
C. The examiner should ask the patient to name objects and repeat phrases
D. The examiner should assess writing only
Answer: C. The examiner should ask the patient to name objects and repeat
phrases
Rationale: Item 9 assesses language through multiple tasks including naming objects,
describing a picture, and repeating phrases. The examiner should evaluate fluency,
comprehension, and repetition.
7. When scoring Item 10 (Dysarthria), what should the examiner do if the patient
is able to speak but has a heavy accent?
A. Score as 1 because speech is not clear
B. Score based on the clarity of speech in the patient's native language
C. Score as 2 because speech is unintelligible to the examiner
D. Not assess because of the accent
Answer: B. Score based on the clarity of speech in the patient's native language
, Rationale: Dysarthria is a motor speech disorder. The examiner should consider the
patient's baseline speech patterns, including accent, and only score abnormalities that are
due to neurological impairment.
8. During assessment of Item 11 (Extinction/Inattention), how should the examiner
test for tactile extinction?
A. Touch the patient on one side and ask if they feel it
B. Touch both sides simultaneously and ask if they feel both
C. Apply a pinprick to the face only
D. Ask the patient to close their eyes and identify a number traced on the palm
Answer: B. Touch both sides simultaneously and ask if they feel both
Rationale: Tactile extinction is tested by simultaneously touching both sides of the body
(e.g., both hands) and asking the patient if they feel both. If they only feel one side,
extinction is present.
9. What is the recommended time frame for completing the NIHSS?
A. 5 minutes
B. 10 minutes
C. 15 minutes
D. 20 minutes
Answer: B. 10 minutes
Rationale: The NIHSS is designed to be completed in approximately 10 minutes or less,
making it practical for acute stroke assessment.
10. A patient is unable to complete the NIHSS due to severe agitation. What
should the examiner do?
Certified Scoring Guide & Clinical Training Materials
[Graded A+]
This definitive clinical reference guide contains the complete set of all National Institutes
of Health Stroke Scale (NIHSS) Test Groups A through F, covering patient case
scenarios 1 through 6. It provides updated clinical training metrics, official scoring
criteria, and differential diagnosis rationales for evaluating acute neurological deficits,
including gaze, visual fields, motor function, ataxia, sensory loss, and language.
Healthcare practitioners, emergency nurses, and neurologists will master the standard
physical assessment protocols required to eliminate scoring variability and successfully
pass their official certification track.
1. Which of the following is the correct action if a patient cannot follow
commands due to a language barrier rather than aphasia?
A. Score Item 1c as 2
B. Use a translator or pantomime to assess command following
C. Skip Item 1c and document as not assessed
D. Score Item 1c as 1
Answer: B. Use a translator or pantomime to assess command following
Rationale: The NIHSS should be administered in the patient's preferred language or with
an interpreter. If a language barrier exists, pantomime and demonstration should be used
before scoring. A score of 2 is only for true inability to follow commands due to
neurological deficit, not language barrier.
2. During assessment of Item 7 (Limb Ataxia), which of the following tests is used
for the upper extremities?
A. Heel-to-shin test
B. Finger-to-nose test
,C. Rapid alternating movements
D. Pronator drift
Answer: B. Finger-to-nose test
Rationale: Item 7 uses the finger-to-nose test for the arms and the heel-to-shin test for the
legs. Ataxia is scored based on the presence of cerebellar-type incoordination.
3. A patient is comatose. How should Item 8 (Sensory) be scored?
A. 0
B. 1
C. 2
D. Not assessed
Answer: C. 2
Rationale: If the patient is comatose or unresponsive, sensory function cannot be reliably
assessed, and Item 8 is scored 2 (severe to total sensory loss).
4. Which of the following is true regarding the administration of Item 1a (Level of
Consciousness)?
A. The examiner should use painful stimulation first
B. The examiner should observe for spontaneous responses before stimulation
C. The examiner should shake the patient vigorously
D. The examiner should only assess verbal responses
Answer: B. The examiner should observe for spontaneous responses before
stimulation
Rationale: Item 1a begins with observation. If the patient is alert and responsive
spontaneously, score 0. If not, the examiner progresses to verbal then painful stimulation.
,5. A patient has a score of 2 on Item 2 (Best Gaze). What is the most likely finding?
A. Normal gaze
B. Partial gaze palsy overcome by oculocephalic reflex
C. Forced deviation not overcome by voluntary or reflexive activity
D. Bilateral gaze palsy
Answer: C. Forced deviation not overcome by voluntary or reflexive activity
Rationale: Item 2 scores 2 for forced deviation that is not overcome by voluntary or
reflexive activity (e.g., oculocephalic maneuver).
6. Which of the following statements about Item 9 (Best Language) is correct?
A. The examiner should only assess spontaneous speech
B. The examiner should use a standardized picture description task
C. The examiner should ask the patient to name objects and repeat phrases
D. The examiner should assess writing only
Answer: C. The examiner should ask the patient to name objects and repeat
phrases
Rationale: Item 9 assesses language through multiple tasks including naming objects,
describing a picture, and repeating phrases. The examiner should evaluate fluency,
comprehension, and repetition.
7. When scoring Item 10 (Dysarthria), what should the examiner do if the patient
is able to speak but has a heavy accent?
A. Score as 1 because speech is not clear
B. Score based on the clarity of speech in the patient's native language
C. Score as 2 because speech is unintelligible to the examiner
D. Not assess because of the accent
Answer: B. Score based on the clarity of speech in the patient's native language
, Rationale: Dysarthria is a motor speech disorder. The examiner should consider the
patient's baseline speech patterns, including accent, and only score abnormalities that are
due to neurological impairment.
8. During assessment of Item 11 (Extinction/Inattention), how should the examiner
test for tactile extinction?
A. Touch the patient on one side and ask if they feel it
B. Touch both sides simultaneously and ask if they feel both
C. Apply a pinprick to the face only
D. Ask the patient to close their eyes and identify a number traced on the palm
Answer: B. Touch both sides simultaneously and ask if they feel both
Rationale: Tactile extinction is tested by simultaneously touching both sides of the body
(e.g., both hands) and asking the patient if they feel both. If they only feel one side,
extinction is present.
9. What is the recommended time frame for completing the NIHSS?
A. 5 minutes
B. 10 minutes
C. 15 minutes
D. 20 minutes
Answer: B. 10 minutes
Rationale: The NIHSS is designed to be completed in approximately 10 minutes or less,
making it practical for acute stroke assessment.
10. A patient is unable to complete the NIHSS due to severe agitation. What
should the examiner do?
