NIH Stroke Scale ACTUAL EXAM 2026/2027 Complete
Certification Answer Key | All Groups A-F Patients 1-6 |
Detailed Rationales | 100% Verified Pass Guaranteed – A+
Graded
Directions: Choose the single best answer for each question. An answer key and instructor
rationale follow every item.
Level of Consciousness and Orientation — NIHSS Items 1a, 1b, 1c (Questions 1–15)
Q1: Item 1a asks you to grade the patient's level of consciousness. Which finding earns a
score of 2?
A. Not alert, but arousable by minor stimulation to obey, answer, or respond
B. Responds only with reflex motor or autonomic effects, or is totally unresponsive
C. Alert and keenly responsive
D. Not alert; requires repeated stimulation to attend, or is obtunded and needs strong or
painful stimulation to make movements [CORRECT]
Correct Answer: D
Rationale: The best answer is D, because a 2 describes a patient who needs repeated
stimulation to attend or strong, painful stimulation to produce purposeful movement.
Arousal to minor stimulation is a 1, and reflex-only or absent response is a 3.
Q2: A 67-year-old admitted with left-sided weakness opens her eyes when you call her
name, follows "squeeze my hand" after a gentle shoulder tap, and drifts back to sleep
between interactions. What is her 1a score?
A. 1 – not alert, but arousable by minor stimulation [CORRECT]
B. 0 – alert and keenly responsive
C. 2 – requires repeated or strong stimulation
D. 3 – unresponsive
Correct Answer: A
Rationale: This choice is correct because she arouses to voice and gentle touch, which is
minor stimulation, matching a score of 1. She is not keenly alert, and she never needed
repeated or painful stimulation to respond.
Q3: Per the NINDS protocol, which set of noxious stimuli is appropriate when a patient does
not respond to your voice during 1a?
A. Loud clapping and shining a bright light in the eyes
B. Cold caloric irrigation only
C. Vigorous shaking of the shoulders until the patient responds
D. Trapezius pinch, nail bed pressure, or sternal rub, applied in a graduated fashion
[CORRECT]
Correct Answer: D
,Rationale: This aligns with the protocol's graduated approach using trapezius pinch, nail bed
pressure, or sternal rub. Shaking is not an accepted stimulus, and cold caloric testing
belongs to gaze assessment, not arousal.
Q4: Following thrombectomy, a man is unresponsive to voice. Sternal rub produces flexion
posturing with no purposeful movement, and trapezius pinch yields the same. Score 1a.
A. 1
B. 2
C. 3 [CORRECT]
D. 4
Correct Answer: C
Rationale: A patient who responds only with reflex motor or autonomic effects, such as
posturing, scores 3. A 2 would require some purposeful movement after strong stimulation,
and 4 is a motor score, not a consciousness score.
Q5: For item 1b, the two questions asked are — and the answers must be —:
A. The day of the week and the patient's age
B. The current month and the patient's exact age [CORRECT]
C. The year and the patient's birth date
D. The hospital name and the current date
Correct Answer: B
Rationale: 1b requires the exact month and the exact age, with no partial credit for close
answers. Weekday, birth date, and location questions are not part of this item.
Q6: It is October. Your patient correctly states his age as 72 but answers "September" when
asked the month. Score 1b.
A. 0
B. 1 [CORRECT]
C. 2
D. UN
Correct Answer: B
Rationale: He answered one of the two questions correctly, which scores 1, since there is no
partial credit and both must be exact for a 0. An incorrect month alone never drops the
score to 2.
Mini-case (Questions 7–8 refer to the same patient): Mr. Delgado, 58, is intubated for
airway protection after a large right MCA infarct. He is alert, tracks you with his eyes, and
squeezes with his right hand when asked, but he cannot speak because of the tube; his left
side is weak.
Q7: How should item 1b be scored for Mr. Delgado?
A. 2, because he cannot answer the questions
B. UN, because the tube prevents testing
C. 1, because speechlessness from intubation is not aphasia and is scored 1 [CORRECT]
D. 0, because he is alert and tracking
Correct Answer: C
, Rationale: This matches the NINDS principle that patients unable to speak because of
intubation — or any problem not secondary to aphasia — receive a 1, while a 2 is reserved
for patients who cannot comprehend the questions at all.
Q8: Continuing with Mr. Delgado: you gesture and ask him to open and close his eyes, then
grip and release your fingers with his right hand. He performs both tasks correctly. Score 1c.
A. 0 [CORRECT]
B. 1
C. 2
D. UN
Correct Answer: A
Rationale: Commands for 1c require performance, not speech, so an intubated patient is
fully testable; carrying out both tasks correctly earns a 0. There is no "untestable" category
for this item, and he completed both, not one.
Q9: A woman with expressive aphasia cannot answer you verbally. You pantomime "close
your eyes" and "make a fist," and she follows both. Score 1c.
A. 2, because aphasia automatically scores 2
B. 1, because she completed only part of the task
C. UN
D. 0 – she performed both tasks after pantomime [CORRECT]
Correct Answer: D
Rationale: Pantomime is permitted for patients who cannot follow spoken commands, and
compliance is scored normally, so two correct performances earn a 0. Aphasia alone never
forces a 2 on this item.
Q10: Which pair of commands is used for item 1c?
A. "State the month" and "make a fist"
B. "Close your eyes" and "make a fist" (or grip and release the non-paretic hand) [CORRECT]
C. "Follow my finger" and "show me your teeth"
D. "Raise both arms" and "squeeze my fingers"
Correct Answer: B
Rationale: 1c uses two simple one-step commands — eyes and grip — with pantomime
allowed. Finger following and teeth-showing belong to gaze and facial palsy, and arm raising
belongs to the motor items.
Q11: Your patient scores 3 on 1a. A colleague suggests filling in the remaining items as zeros
to save time. What is the correct practice?
A. Score all remaining items UN
B. Record zeros for the remaining items to avoid inflating the total
C. Assess every remaining item — using noxious stimuli, oculocephalic maneuvers, and
visual threat as needed — and score the best response observed [CORRECT]
D. Score only the motor items in a comatose patient
Correct Answer: C
Rationale: This aligns with the principle that even comatose patients receive a complete
NIHSS, because reflex testing, oculocephalics, and visual threat allow every item to be
graded; defaulting to zeros hides real findings and distorts severity.
Certification Answer Key | All Groups A-F Patients 1-6 |
Detailed Rationales | 100% Verified Pass Guaranteed – A+
Graded
Directions: Choose the single best answer for each question. An answer key and instructor
rationale follow every item.
Level of Consciousness and Orientation — NIHSS Items 1a, 1b, 1c (Questions 1–15)
Q1: Item 1a asks you to grade the patient's level of consciousness. Which finding earns a
score of 2?
A. Not alert, but arousable by minor stimulation to obey, answer, or respond
B. Responds only with reflex motor or autonomic effects, or is totally unresponsive
C. Alert and keenly responsive
D. Not alert; requires repeated stimulation to attend, or is obtunded and needs strong or
painful stimulation to make movements [CORRECT]
Correct Answer: D
Rationale: The best answer is D, because a 2 describes a patient who needs repeated
stimulation to attend or strong, painful stimulation to produce purposeful movement.
Arousal to minor stimulation is a 1, and reflex-only or absent response is a 3.
Q2: A 67-year-old admitted with left-sided weakness opens her eyes when you call her
name, follows "squeeze my hand" after a gentle shoulder tap, and drifts back to sleep
between interactions. What is her 1a score?
A. 1 – not alert, but arousable by minor stimulation [CORRECT]
B. 0 – alert and keenly responsive
C. 2 – requires repeated or strong stimulation
D. 3 – unresponsive
Correct Answer: A
Rationale: This choice is correct because she arouses to voice and gentle touch, which is
minor stimulation, matching a score of 1. She is not keenly alert, and she never needed
repeated or painful stimulation to respond.
Q3: Per the NINDS protocol, which set of noxious stimuli is appropriate when a patient does
not respond to your voice during 1a?
A. Loud clapping and shining a bright light in the eyes
B. Cold caloric irrigation only
C. Vigorous shaking of the shoulders until the patient responds
D. Trapezius pinch, nail bed pressure, or sternal rub, applied in a graduated fashion
[CORRECT]
Correct Answer: D
,Rationale: This aligns with the protocol's graduated approach using trapezius pinch, nail bed
pressure, or sternal rub. Shaking is not an accepted stimulus, and cold caloric testing
belongs to gaze assessment, not arousal.
Q4: Following thrombectomy, a man is unresponsive to voice. Sternal rub produces flexion
posturing with no purposeful movement, and trapezius pinch yields the same. Score 1a.
A. 1
B. 2
C. 3 [CORRECT]
D. 4
Correct Answer: C
Rationale: A patient who responds only with reflex motor or autonomic effects, such as
posturing, scores 3. A 2 would require some purposeful movement after strong stimulation,
and 4 is a motor score, not a consciousness score.
Q5: For item 1b, the two questions asked are — and the answers must be —:
A. The day of the week and the patient's age
B. The current month and the patient's exact age [CORRECT]
C. The year and the patient's birth date
D. The hospital name and the current date
Correct Answer: B
Rationale: 1b requires the exact month and the exact age, with no partial credit for close
answers. Weekday, birth date, and location questions are not part of this item.
Q6: It is October. Your patient correctly states his age as 72 but answers "September" when
asked the month. Score 1b.
A. 0
B. 1 [CORRECT]
C. 2
D. UN
Correct Answer: B
Rationale: He answered one of the two questions correctly, which scores 1, since there is no
partial credit and both must be exact for a 0. An incorrect month alone never drops the
score to 2.
Mini-case (Questions 7–8 refer to the same patient): Mr. Delgado, 58, is intubated for
airway protection after a large right MCA infarct. He is alert, tracks you with his eyes, and
squeezes with his right hand when asked, but he cannot speak because of the tube; his left
side is weak.
Q7: How should item 1b be scored for Mr. Delgado?
A. 2, because he cannot answer the questions
B. UN, because the tube prevents testing
C. 1, because speechlessness from intubation is not aphasia and is scored 1 [CORRECT]
D. 0, because he is alert and tracking
Correct Answer: C
, Rationale: This matches the NINDS principle that patients unable to speak because of
intubation — or any problem not secondary to aphasia — receive a 1, while a 2 is reserved
for patients who cannot comprehend the questions at all.
Q8: Continuing with Mr. Delgado: you gesture and ask him to open and close his eyes, then
grip and release your fingers with his right hand. He performs both tasks correctly. Score 1c.
A. 0 [CORRECT]
B. 1
C. 2
D. UN
Correct Answer: A
Rationale: Commands for 1c require performance, not speech, so an intubated patient is
fully testable; carrying out both tasks correctly earns a 0. There is no "untestable" category
for this item, and he completed both, not one.
Q9: A woman with expressive aphasia cannot answer you verbally. You pantomime "close
your eyes" and "make a fist," and she follows both. Score 1c.
A. 2, because aphasia automatically scores 2
B. 1, because she completed only part of the task
C. UN
D. 0 – she performed both tasks after pantomime [CORRECT]
Correct Answer: D
Rationale: Pantomime is permitted for patients who cannot follow spoken commands, and
compliance is scored normally, so two correct performances earn a 0. Aphasia alone never
forces a 2 on this item.
Q10: Which pair of commands is used for item 1c?
A. "State the month" and "make a fist"
B. "Close your eyes" and "make a fist" (or grip and release the non-paretic hand) [CORRECT]
C. "Follow my finger" and "show me your teeth"
D. "Raise both arms" and "squeeze my fingers"
Correct Answer: B
Rationale: 1c uses two simple one-step commands — eyes and grip — with pantomime
allowed. Finger following and teeth-showing belong to gaze and facial palsy, and arm raising
belongs to the motor items.
Q11: Your patient scores 3 on 1a. A colleague suggests filling in the remaining items as zeros
to save time. What is the correct practice?
A. Score all remaining items UN
B. Record zeros for the remaining items to avoid inflating the total
C. Assess every remaining item — using noxious stimuli, oculocephalic maneuvers, and
visual threat as needed — and score the best response observed [CORRECT]
D. Score only the motor items in a comatose patient
Correct Answer: C
Rationale: This aligns with the principle that even comatose patients receive a complete
NIHSS, because reflex testing, oculocephalics, and visual threat allow every item to be
graded; defaulting to zeros hides real findings and distorts severity.
