NIHSS Group A Certification Exam — 2026/2027 Page 1
NIHSS Group A Certification Exam
Questions with Correct Answers — 2026/2027 Edition
Examination Overview
This examination is the official 2026/2027 Group A certification instrument of the National Institutes of Health Stroke
Scale (NIHSS). The exam comprises 66 scenario-based questions organized into 6 patient scenarios, with each patient
receiving complete item-by-item NIHSS scoring across all 11 domains (Items 1a through 11). Each question presents a
clinical finding and four scoring options (A–D); exactly one option represents the verified NIHSS score. A rationale
based on standardized NIHSS examination protocol, scoring definitions, and clinical significance accompanies every
answer. Cognitive distribution: 30% recall (scoring definitions), 50% application (patient scenario scoring), 20% analysis
(differentiating subtle neurological findings).
Examination Instructions
1. Read each patient scenario carefully and identify the specific NIHSS item being scored.
2. Select the single best answer (A, B, C, or D) corresponding to the verified NIHSS score.
3. Each correct answer is marked with **[CORRECT]** and accompanied by a NIHSS-specific rationale.
4. Apply standardized NIHSS examination protocol: 2026/2027 updates include refined ataxia scoring rules, aphasia vs
dysarthria differentiation criteria, and updated untestable item handling for intubated or comatose patients.
5. Score ranges: Item 1a (0–3), 1b (0–2), 1c (0–2), Items 2–4 (0–2 or 0–3), Items 5a/5b/6a/6b (0–4), Item 7 (0–2), Items
8–11 (0–2 or 0–3). Untestable items receive default scores per NIHSS protocol.
NIHSS Item Legend (Items 1a–11)
Item Domain Score Range
1a Level of Consciousness — Alertness 0–3
1b LOC — Orientation Questions (Month & Age) 0–2
1c LOC — Commands (Open/Close Eyes, Grip/Release) 0–2
2 Best Gaze 0–2
3 Visual Fields (No loss / Partial / Complete / Bilateral hemianopia) 0–3
4 Facial Palsy (Normal / Minor / Partial / Complete) 0–3
5a Motor Arm — Left (No drift / Drift / Some effort / No effort / No movement) 0–4
5b Motor Arm — Right 0–4
6a Motor Leg — Left (No drift / Drift / Some effort / No effort / No movement) 0–4
6b Motor Leg — Right 0–4
7 Limb Ataxia (Absent / One limb / Two+ limbs) 0–2
8 Sensory (Normal / Mild-to-moderate / Severe-to-total) 0–2
9 Best Language (No aphasia / Mild-mod / Severe / Mute) 0–3
10 Dysarthria (Normal / Mild-mod / Severe / Untestable) 0–2
11 Extinction & Inattention (None / Partial / Complete) 0–2
Section 1: Group A Patient 1 — Complete NIHSS Scoring (Q1–Q11)
NIHSS Group A — 6 Patients × 11 Items = 66 Questions Verified Answers & Rationales
,NIHSS Group A Certification Exam — 2026/2027 Page 2
Patient 1 Scenario: A 67-year-old man presents 90 minutes after acute onset of right-sided weakness and slurred
speech. He is somnolent on arrival but arouses to verbal stimulation. He has a left gaze preference, partial right
visual field loss, mild right facial droop, right arm drift, right leg drift, and dysmetria on right finger-to-nose and
heel-to-shin testing. CT shows a left MCA territory hypoattenuation. The examiner administers the full NIHSS in
standardized order.
Q1: [Group A Patient 1 — NIHSS Item 1a: Level of Consciousness — Alertness] When you approach the
bedside, the patient is lying with eyes closed. You call his name and he opens his eyes, makes eye contact,
but becomes drowsy again within 10 seconds. He responds consistently to minor verbal stimulation (saying
his name) but does not remain alert without ongoing prompting. Noxious stimulation is not required.
A. 0 - Alert; keenly responsive
B. 1 - Not alert, but arousable by minor stimulation **[CORRECT]**
C. 2 - Not alert, requires repeated stimulation to attend
D. 3 - Coma, unresponsive to all stimuli
Correct Answer: B
Rationale: Score 1 (Not alert, but arousable by minor stimulation) is correct because the patient responds to minor
verbal stimulation (his name) but does not sustain alertness. Score 0 requires sustained alertness; score 2 requires the
need for repeated or noxious stimulation to maintain attention; score 3 is reserved for coma with no response.
Q2: [Group A Patient 1 — NIHSS Item 1b: Level of Consciousness — Orientation Questions] You ask the
patient: 'What month is it?' He answers 'September' (the correct answer is October). You then ask: 'How
old are you?' He correctly answers '67.' Both answers must be 100% correct for the orientation score;
partial credit is not given within an item.
A. 0 - Both questions answered correctly
B. 1 - One question answered correctly **[CORRECT]**
C. 2 - Neither question answered correctly
D. Untestable - patient cannot answer due to aphasia or coma
Correct Answer: B
Rationale: Score 1 (One correct) is correct because the patient correctly states his age (67) but incorrectly identifies the
month. NIHSS scoring requires both the month and age to be 100% correct for score 0; one error yields score 1. Score 2
is reserved for neither correct, and 'Untestable' is reserved for aphasic or comatose patients who cannot answer.
Q3: [Group A Patient 1 — NIHSS Item 1c: Level of Consciousness — Commands] You ask the patient to
'Open and close your eyes' — he does so correctly. You then ask him to 'Grip and release your hand' — he
grips and releases the examiner's fingers with the left (unaffected) hand without difficulty. The right hand
has motor weakness preventing grip, so the substitute hand is accepted per NIHSS protocol.
A. 0 - Both tasks performed correctly **[CORRECT]**
B. 1 - One task performed correctly
C. 2 - Neither task performed correctly
D. Untestable - patient cannot follow any commands
Correct Answer: A
Rationale: Score 0 (Both tasks correct) is correct because the patient performs both the eye open/close and grip/release
commands. NIHSS allows substitution of the unaffected hand for grip testing when the affected hand cannot grip;
since the patient performed both tasks via acceptable substitution, no deduction is warranted. Score 1 applies if only one
task is performed, score 2 if neither.
Q4: [Group A Patient 1 — NIHSS Item 2: Best Gaze] On examination, the patient's eyes have a slight
leftward preference at rest. When you ask him to 'look left, look right,' he can move his eyes horizontally in
both directions voluntarily, although the leftward gaze is slightly more sustained. There is no forced
NIHSS Group A — 6 Patients × 11 Items = 66 Questions Verified Answers & Rationales
, NIHSS Group A Certification Exam — 2026/2027 Page 3
deviation, and the oculocephalic (Doll's eye) reflex is preserved.
A. 0 - Normal horizontal movement of both eyes
B. 1 - Partial gaze palsy; gaze is abnormal in one or both eyes but no forced deviation **[CORRECT]**
C. 2 - Forced deviation or total gaze paresis not overcome by voluntary or reflexive movement
D. Untestable - patient cannot participate in gaze testing
Correct Answer: B
Rationale: Score 1 (Partial gaze palsy) is correct because the patient has a gaze preference at rest but can voluntarily
move both eyes horizontally, indicating the deviation can be overcome. Score 0 requires normal gaze without
preference; score 2 requires forced deviation that cannot be overcome by voluntary or reflexive (oculocephalic)
movement. The preserved Doll's eye reflex excludes untestable.
Q5: [Group A Patient 1 — NIHSS Item 3: Visual Fields] On confrontation visual field testing using finger
movement, the patient correctly identifies finger wiggle in all four quadrants of the right visual field, and
in the upper left quadrant. However, he fails to identify finger wiggle in the lower left quadrant. The deficit
is consistent across multiple trials.
A. 0 - No visual loss
B. 1 - Partial hemianopia; loss in one quadrant or asymmetric extinction **[CORRECT]**
C. 2 - Complete hemianopia; loss of half the visual field in one or both eyes
D. 3 - Bilateral hemianopia or cortical blindness
Correct Answer: B
Rationale: Score 1 (Partial hemianopia) is correct because the patient has loss confined to one quadrant (lower left) of
the visual field. NIHSS Item 3 distinguishes partial (one quadrant, asymmetric extinction) from complete (half-field
loss) and bilateral hemianopia (both halves). Score 0 requires intact visual fields; score 2 requires complete
hemianopia; score 3 is reserved for bilateral blindness including cortical.
Q6: [Group A Patient 1 — NIHSS Item 4: Facial Palsy] On inspection, the patient has a slight flattening of
the right nasolabial fold at rest. When asked to smile and show teeth, the right corner of the mouth elevates
slightly less than the left, and the right nasolabial fold deepens less than the left. Eye closure is symmetric
and full; forehead movement is symmetric.
A. 0 - Normal symmetrical facial movement
B. 1 - Minor paralysis; flattened nasolabial fold or slight asymmetry on smile **[CORRECT]**
C. 2 - Partial paralysis; lower face paralysis with marked asymmetry on smile
D. 3 - Complete unilateral or bilateral facial paralysis, no movement
Correct Answer: B
Rationale: Score 1 (Minor paralysis) is correct because the patient demonstrates only slight nasolabial fold flattening
and mild smile asymmetry, with preserved forehead and eye closure. NIHSS Item 4 scoring: score 0 is symmetric; score
1 requires minor asymmetry; score 2 requires pronounced lower face paralysis with marked smile asymmetry; score 3
requires complete unilateral or bilateral paralysis including upper face.
Q7: [Group A Patient 1 — NIHSS Item 5a: Motor Arm — Left (No drift / Drift / Some effort / No effort /
No movement)] You ask the patient to extend his left arm to 90 degrees (or 45 degrees if supine) and hold
for 10 seconds. He lifts the arm promptly to 90 degrees and holds it steadily for the full 10 seconds without
drift. The left arm is the unaffected side.
A. 0 - No drift; arm holds 90 (or 45) degrees for full 10 seconds **[CORRECT]**
B. 1 - Drift; arm holds 90 degrees but drifts down before 10 seconds without hitting bed
C. 2 - Some effort against gravity; arm cannot reach 90 degrees, drifts down to bed
D. 3 - No effort against gravity; arm falls immediately
Correct Answer: A
NIHSS Group A — 6 Patients × 11 Items = 66 Questions Verified Answers & Rationales
NIHSS Group A Certification Exam
Questions with Correct Answers — 2026/2027 Edition
Examination Overview
This examination is the official 2026/2027 Group A certification instrument of the National Institutes of Health Stroke
Scale (NIHSS). The exam comprises 66 scenario-based questions organized into 6 patient scenarios, with each patient
receiving complete item-by-item NIHSS scoring across all 11 domains (Items 1a through 11). Each question presents a
clinical finding and four scoring options (A–D); exactly one option represents the verified NIHSS score. A rationale
based on standardized NIHSS examination protocol, scoring definitions, and clinical significance accompanies every
answer. Cognitive distribution: 30% recall (scoring definitions), 50% application (patient scenario scoring), 20% analysis
(differentiating subtle neurological findings).
Examination Instructions
1. Read each patient scenario carefully and identify the specific NIHSS item being scored.
2. Select the single best answer (A, B, C, or D) corresponding to the verified NIHSS score.
3. Each correct answer is marked with **[CORRECT]** and accompanied by a NIHSS-specific rationale.
4. Apply standardized NIHSS examination protocol: 2026/2027 updates include refined ataxia scoring rules, aphasia vs
dysarthria differentiation criteria, and updated untestable item handling for intubated or comatose patients.
5. Score ranges: Item 1a (0–3), 1b (0–2), 1c (0–2), Items 2–4 (0–2 or 0–3), Items 5a/5b/6a/6b (0–4), Item 7 (0–2), Items
8–11 (0–2 or 0–3). Untestable items receive default scores per NIHSS protocol.
NIHSS Item Legend (Items 1a–11)
Item Domain Score Range
1a Level of Consciousness — Alertness 0–3
1b LOC — Orientation Questions (Month & Age) 0–2
1c LOC — Commands (Open/Close Eyes, Grip/Release) 0–2
2 Best Gaze 0–2
3 Visual Fields (No loss / Partial / Complete / Bilateral hemianopia) 0–3
4 Facial Palsy (Normal / Minor / Partial / Complete) 0–3
5a Motor Arm — Left (No drift / Drift / Some effort / No effort / No movement) 0–4
5b Motor Arm — Right 0–4
6a Motor Leg — Left (No drift / Drift / Some effort / No effort / No movement) 0–4
6b Motor Leg — Right 0–4
7 Limb Ataxia (Absent / One limb / Two+ limbs) 0–2
8 Sensory (Normal / Mild-to-moderate / Severe-to-total) 0–2
9 Best Language (No aphasia / Mild-mod / Severe / Mute) 0–3
10 Dysarthria (Normal / Mild-mod / Severe / Untestable) 0–2
11 Extinction & Inattention (None / Partial / Complete) 0–2
Section 1: Group A Patient 1 — Complete NIHSS Scoring (Q1–Q11)
NIHSS Group A — 6 Patients × 11 Items = 66 Questions Verified Answers & Rationales
,NIHSS Group A Certification Exam — 2026/2027 Page 2
Patient 1 Scenario: A 67-year-old man presents 90 minutes after acute onset of right-sided weakness and slurred
speech. He is somnolent on arrival but arouses to verbal stimulation. He has a left gaze preference, partial right
visual field loss, mild right facial droop, right arm drift, right leg drift, and dysmetria on right finger-to-nose and
heel-to-shin testing. CT shows a left MCA territory hypoattenuation. The examiner administers the full NIHSS in
standardized order.
Q1: [Group A Patient 1 — NIHSS Item 1a: Level of Consciousness — Alertness] When you approach the
bedside, the patient is lying with eyes closed. You call his name and he opens his eyes, makes eye contact,
but becomes drowsy again within 10 seconds. He responds consistently to minor verbal stimulation (saying
his name) but does not remain alert without ongoing prompting. Noxious stimulation is not required.
A. 0 - Alert; keenly responsive
B. 1 - Not alert, but arousable by minor stimulation **[CORRECT]**
C. 2 - Not alert, requires repeated stimulation to attend
D. 3 - Coma, unresponsive to all stimuli
Correct Answer: B
Rationale: Score 1 (Not alert, but arousable by minor stimulation) is correct because the patient responds to minor
verbal stimulation (his name) but does not sustain alertness. Score 0 requires sustained alertness; score 2 requires the
need for repeated or noxious stimulation to maintain attention; score 3 is reserved for coma with no response.
Q2: [Group A Patient 1 — NIHSS Item 1b: Level of Consciousness — Orientation Questions] You ask the
patient: 'What month is it?' He answers 'September' (the correct answer is October). You then ask: 'How
old are you?' He correctly answers '67.' Both answers must be 100% correct for the orientation score;
partial credit is not given within an item.
A. 0 - Both questions answered correctly
B. 1 - One question answered correctly **[CORRECT]**
C. 2 - Neither question answered correctly
D. Untestable - patient cannot answer due to aphasia or coma
Correct Answer: B
Rationale: Score 1 (One correct) is correct because the patient correctly states his age (67) but incorrectly identifies the
month. NIHSS scoring requires both the month and age to be 100% correct for score 0; one error yields score 1. Score 2
is reserved for neither correct, and 'Untestable' is reserved for aphasic or comatose patients who cannot answer.
Q3: [Group A Patient 1 — NIHSS Item 1c: Level of Consciousness — Commands] You ask the patient to
'Open and close your eyes' — he does so correctly. You then ask him to 'Grip and release your hand' — he
grips and releases the examiner's fingers with the left (unaffected) hand without difficulty. The right hand
has motor weakness preventing grip, so the substitute hand is accepted per NIHSS protocol.
A. 0 - Both tasks performed correctly **[CORRECT]**
B. 1 - One task performed correctly
C. 2 - Neither task performed correctly
D. Untestable - patient cannot follow any commands
Correct Answer: A
Rationale: Score 0 (Both tasks correct) is correct because the patient performs both the eye open/close and grip/release
commands. NIHSS allows substitution of the unaffected hand for grip testing when the affected hand cannot grip;
since the patient performed both tasks via acceptable substitution, no deduction is warranted. Score 1 applies if only one
task is performed, score 2 if neither.
Q4: [Group A Patient 1 — NIHSS Item 2: Best Gaze] On examination, the patient's eyes have a slight
leftward preference at rest. When you ask him to 'look left, look right,' he can move his eyes horizontally in
both directions voluntarily, although the leftward gaze is slightly more sustained. There is no forced
NIHSS Group A — 6 Patients × 11 Items = 66 Questions Verified Answers & Rationales
, NIHSS Group A Certification Exam — 2026/2027 Page 3
deviation, and the oculocephalic (Doll's eye) reflex is preserved.
A. 0 - Normal horizontal movement of both eyes
B. 1 - Partial gaze palsy; gaze is abnormal in one or both eyes but no forced deviation **[CORRECT]**
C. 2 - Forced deviation or total gaze paresis not overcome by voluntary or reflexive movement
D. Untestable - patient cannot participate in gaze testing
Correct Answer: B
Rationale: Score 1 (Partial gaze palsy) is correct because the patient has a gaze preference at rest but can voluntarily
move both eyes horizontally, indicating the deviation can be overcome. Score 0 requires normal gaze without
preference; score 2 requires forced deviation that cannot be overcome by voluntary or reflexive (oculocephalic)
movement. The preserved Doll's eye reflex excludes untestable.
Q5: [Group A Patient 1 — NIHSS Item 3: Visual Fields] On confrontation visual field testing using finger
movement, the patient correctly identifies finger wiggle in all four quadrants of the right visual field, and
in the upper left quadrant. However, he fails to identify finger wiggle in the lower left quadrant. The deficit
is consistent across multiple trials.
A. 0 - No visual loss
B. 1 - Partial hemianopia; loss in one quadrant or asymmetric extinction **[CORRECT]**
C. 2 - Complete hemianopia; loss of half the visual field in one or both eyes
D. 3 - Bilateral hemianopia or cortical blindness
Correct Answer: B
Rationale: Score 1 (Partial hemianopia) is correct because the patient has loss confined to one quadrant (lower left) of
the visual field. NIHSS Item 3 distinguishes partial (one quadrant, asymmetric extinction) from complete (half-field
loss) and bilateral hemianopia (both halves). Score 0 requires intact visual fields; score 2 requires complete
hemianopia; score 3 is reserved for bilateral blindness including cortical.
Q6: [Group A Patient 1 — NIHSS Item 4: Facial Palsy] On inspection, the patient has a slight flattening of
the right nasolabial fold at rest. When asked to smile and show teeth, the right corner of the mouth elevates
slightly less than the left, and the right nasolabial fold deepens less than the left. Eye closure is symmetric
and full; forehead movement is symmetric.
A. 0 - Normal symmetrical facial movement
B. 1 - Minor paralysis; flattened nasolabial fold or slight asymmetry on smile **[CORRECT]**
C. 2 - Partial paralysis; lower face paralysis with marked asymmetry on smile
D. 3 - Complete unilateral or bilateral facial paralysis, no movement
Correct Answer: B
Rationale: Score 1 (Minor paralysis) is correct because the patient demonstrates only slight nasolabial fold flattening
and mild smile asymmetry, with preserved forehead and eye closure. NIHSS Item 4 scoring: score 0 is symmetric; score
1 requires minor asymmetry; score 2 requires pronounced lower face paralysis with marked smile asymmetry; score 3
requires complete unilateral or bilateral paralysis including upper face.
Q7: [Group A Patient 1 — NIHSS Item 5a: Motor Arm — Left (No drift / Drift / Some effort / No effort /
No movement)] You ask the patient to extend his left arm to 90 degrees (or 45 degrees if supine) and hold
for 10 seconds. He lifts the arm promptly to 90 degrees and holds it steadily for the full 10 seconds without
drift. The left arm is the unaffected side.
A. 0 - No drift; arm holds 90 (or 45) degrees for full 10 seconds **[CORRECT]**
B. 1 - Drift; arm holds 90 degrees but drifts down before 10 seconds without hitting bed
C. 2 - Some effort against gravity; arm cannot reach 90 degrees, drifts down to bed
D. 3 - No effort against gravity; arm falls immediately
Correct Answer: A
NIHSS Group A — 6 Patients × 11 Items = 66 Questions Verified Answers & Rationales
