NIHSS - LEVEL 1 EXAM QUESTIONS
AND ANSWERS 2026 VERIFIED.
The patient is asked the month and his/her age. The answer must be correct - there is no partial
credit for being close. Aphasic and stuporous patients who do not comprehend the questions
will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma,
severe dysarthria from any cause, language barrier or any other problem not secondary to
aphasia are given a 1. It is important that only the initial answer be graded and that the
examiner not help the patient with verbal or non-verbal cues. - ANS 1b. LOC Questions
1-Answers One Question Correctly
The patient is asked to open and close the eyes and then to grip and release the non-paretic
hand. Substitute another one step command if the hands cannot be used. Credit is given if an
unequivocal attempt is made but not completed due to weakness. If the patient does not
respond to command, the task should be demonstrated to them (pantomime) and score the
result (i.e., follows none, one or two commands). Patients with trauma, amputation, or other
physical impediments should be given suitable one-step commands. Only the first attempt is
scored. - ANS 1c. LOC Commands
0- Performs both Tasks Correctly
Only horizontal eye movements will be tested.Voluntary or reflexive (oculocephalic) eye
movements will be scored but caloric testing is not done. If the patient has a conjugate
deviation of the eyes that can be overcome by voluntary or reflexive activity, the score will be 1.
If a patient has an isolated peripheral nerve paresis (CN III, IV or VI) score a 1. Gaze is testable in
all aphasic patients. Patients with ocular trauma, bandages, pre-existing blindness or other
disorder of visual acuity or fields should be tested with reflexive movements and a choice made
by the investigator. Establishing eye contact and then moving about the patient from side to
side will occasionally clarify the presence of a partial gaze palsy. - ANS 2. best Gaze
0-Normal
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, Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or
visual threat as appropriate. Patient must be encouraged, but if they look at the side of the
moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or
enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-cut asymmetry,
including quadrantanopia is found. If patient is blind from any cause score 3. Double
simultaneous stimulation is performed at this point. If there is extinction patient receives a 1,
and the results are used to answer question 11. - ANS 3. Visual
0-No Visual Loss
Ask, or use pantomime to encourage the patient to show teeth or raise eyebrows and close
eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non-
comprehending patient. If facial trauma/bandages, orotracheal tube, tape or other physical
barriers obscure the face, these should be removed to the extent possible. - ANS 4. Facial
Palsy
1-Minor Paralysis (Flattened nasolabial fold, asymmetry on smiling).
The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if
sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic
patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation.
Each limb is tested in turn, beginning with the non-paretic arm. Only in the case of amputation
or joint fusion at the shoulder, the examiner should record the score as untestable (UN). -
ANS 5a. Motor Arm Left
0- No drift, limb holds 90 (or 45) degrees for full 10 seconds.
The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if
sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic
patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation.
Each limb is tested in turn, beginning with the non-paretic arm. Only in the case of amputation
or joint fusion at the shoulder, the examiner should record the score as untestable (UN). -
ANS 5b. Motor Arm Right
4-No Movement
The limb is placed in the appropriate position: hold the leg at 30 degrees (always tested supine).
Drift is scored if the leg falls before 5 seconds. The aphasic patient is encouraged using urgency
in the voice and pantomime but not noxious stimulation. Each limb is tested in turn, beginning
with the non-paretic leg. Only in the case of amputation or joint fusion at the hip, the examiner
should record the score as untestable (UN). - ANS 6a. Motor Leg Left
@COPYRIGHT ALL RIGHTS RESERVED PAGE 2 OF 11
AND ANSWERS 2026 VERIFIED.
The patient is asked the month and his/her age. The answer must be correct - there is no partial
credit for being close. Aphasic and stuporous patients who do not comprehend the questions
will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma,
severe dysarthria from any cause, language barrier or any other problem not secondary to
aphasia are given a 1. It is important that only the initial answer be graded and that the
examiner not help the patient with verbal or non-verbal cues. - ANS 1b. LOC Questions
1-Answers One Question Correctly
The patient is asked to open and close the eyes and then to grip and release the non-paretic
hand. Substitute another one step command if the hands cannot be used. Credit is given if an
unequivocal attempt is made but not completed due to weakness. If the patient does not
respond to command, the task should be demonstrated to them (pantomime) and score the
result (i.e., follows none, one or two commands). Patients with trauma, amputation, or other
physical impediments should be given suitable one-step commands. Only the first attempt is
scored. - ANS 1c. LOC Commands
0- Performs both Tasks Correctly
Only horizontal eye movements will be tested.Voluntary or reflexive (oculocephalic) eye
movements will be scored but caloric testing is not done. If the patient has a conjugate
deviation of the eyes that can be overcome by voluntary or reflexive activity, the score will be 1.
If a patient has an isolated peripheral nerve paresis (CN III, IV or VI) score a 1. Gaze is testable in
all aphasic patients. Patients with ocular trauma, bandages, pre-existing blindness or other
disorder of visual acuity or fields should be tested with reflexive movements and a choice made
by the investigator. Establishing eye contact and then moving about the patient from side to
side will occasionally clarify the presence of a partial gaze palsy. - ANS 2. best Gaze
0-Normal
@COPYRIGHT ALL RIGHTS RESERVED PAGE 1 OF 11
, Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or
visual threat as appropriate. Patient must be encouraged, but if they look at the side of the
moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or
enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-cut asymmetry,
including quadrantanopia is found. If patient is blind from any cause score 3. Double
simultaneous stimulation is performed at this point. If there is extinction patient receives a 1,
and the results are used to answer question 11. - ANS 3. Visual
0-No Visual Loss
Ask, or use pantomime to encourage the patient to show teeth or raise eyebrows and close
eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non-
comprehending patient. If facial trauma/bandages, orotracheal tube, tape or other physical
barriers obscure the face, these should be removed to the extent possible. - ANS 4. Facial
Palsy
1-Minor Paralysis (Flattened nasolabial fold, asymmetry on smiling).
The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if
sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic
patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation.
Each limb is tested in turn, beginning with the non-paretic arm. Only in the case of amputation
or joint fusion at the shoulder, the examiner should record the score as untestable (UN). -
ANS 5a. Motor Arm Left
0- No drift, limb holds 90 (or 45) degrees for full 10 seconds.
The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if
sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic
patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation.
Each limb is tested in turn, beginning with the non-paretic arm. Only in the case of amputation
or joint fusion at the shoulder, the examiner should record the score as untestable (UN). -
ANS 5b. Motor Arm Right
4-No Movement
The limb is placed in the appropriate position: hold the leg at 30 degrees (always tested supine).
Drift is scored if the leg falls before 5 seconds. The aphasic patient is encouraged using urgency
in the voice and pantomime but not noxious stimulation. Each limb is tested in turn, beginning
with the non-paretic leg. Only in the case of amputation or joint fusion at the hip, the examiner
should record the score as untestable (UN). - ANS 6a. Motor Leg Left
@COPYRIGHT ALL RIGHTS RESERVED PAGE 2 OF 11
