NIH STROKE SCALE (NIHSS)
CERTIFICATION GROUP D
EXAM – 200 Q&A WITH
RATIONALES (VERIFIED)
NIH Stroke Scale (NIHSS) Certification Group D Examination
Question 1
A 64-year-old patient presents with an acute ischemic stroke. During the
initial assessment, the patient is fully awake, alert, and responds
immediately and appropriately to all verbal stimuli. How should the
clinician score Item 1a (Level of Consciousness)?
A. 1 – Not alert; arousable by minor stimulation
B. 0 – Alert; keenly responsive
C. 2 – Not alert; requires repeated stimulation to attend
D. 3 – Comatose; responds only with reflex motor or autonomic effects
Rationale: A score of 0 is correct because the patient is fully awake,
alert, and keenly responsive to environmental and verbal stimuli
without requiring any extra sensory stimulation.
Question 2
The clinician is assessing a patient’s Level of Consciousness Questions
(Item 1b). The patient is asked the current month and their current age.
The patient answers the month correctly but states their age incorrectly
by two years. What score should be assigned?
A. 0 – Answers both questions correctly
B. 1 – Answers one question correctly
C. 2 – Answers neither question correctly
D. 1 – Answers neither question correctly due to a language barrier
Rationale: Item 1b requires exact correctness. Since the patient
answered only one of the two questions accurately (the month), they
receive a score of 1. No partial credit is given for being close to the
correct age.
,Question 3
During the assessment of Item 1c (LOC Commands), a patient is
instructed to open and close their eyes, and then to grip and release their
non-paretic hand. The patient successfully opens and closes their eyes
but fails to respond to the hand grip command despite physical
demonstration. What is the correct score?
A. 0 – Performs both tasks correctly
B. 1 – Performs one task correctly
C. 2 – Performs neither task correctly
D. 1 – Patient attempted both but lacked physical strength
Rationale: The patient only completed one of the two distinct
commands successfully. Item 1c scores 0 for both correct, 1 for one
correct, and 2 for neither correct.
Question 4
A clinician evaluates a patient’s Best Gaze (Item 2). The patient exhibits
a partial gaze palsy where lateral eye movements are restricted in one
eye, but forced deviation is not present. The gaze deficit can be overcome
by voluntary tracking. What score is appropriate?
A. 0 – Normal
B. 1 – Partial gaze palsy; gaze is abnormal in one or both eyes
C. 2 – Forced deviation; total gaze paresis not overcome by the
oculocephalic maneuver
D. 1 – Total gaze paresis that resolves with blinking
Rationale: A partial gaze palsy is scored as a 1 when horizontal eye
movements are limited but total, fixed deviation is absent.
Question 5
When evaluating Visual Fields (Item 3) via confrontation, a patient
exhibits a clear and consistent quadrantanopia in the lower left visual
field. How should this finding be scored?
A. 0 – No visual loss
B. 1 – Partial hemianopia
C. 2 – Complete hemianopia
D. 3 – Bilateral hemianopia or blindness
Rationale: A quadrantanopia represents an asymmetric partial loss of
the visual field, which warrants a score of 1 under the NIHSS criteria.
Question 6
,A patient with an acute right-hemisphere stroke presents with a
complete flattening of the left nasolabial fold and an inability to smile or
clear air on the left side of the face. When looking at the upper face, the
patient can wrinkle their forehead and close both eyes tightly. What is
the correct score for Facial Palsy (Item 4)?
A. 0 – Normal symmetrical movements
B. 1 – Minor paralysis; flattened nasolabial fold
C. 2 – Partial paralysis; total or near-total paralysis of the
lower face
C. 3 – Complete paralysis of one or both sides; absence of facial
movement in upper and lower face
Rationale: Central facial weakness affecting the lower half of the face
completely or near-completely scales as a 2 (partial paralysis).
Question 7
The clinician tests the left arm for Motor Arm strength (Item 5a). The
patient lifts the left arm to 90 degrees while sitting, but the arm drifts
down and hits the bed at precisely 4 seconds. The patient cannot re-
elevate the limb against gravity. What is the correct score?
A. 1 – Drift; limb holds 90 degrees but drifts before 10 seconds
B. 2 – Some effort against gravity; limb cannot attain or
maintain 90 degrees
C. 3 – No effort against gravity; limb falls immediately
D. 4 – No movement at all
Rationale: Because the limb drifted down completely to the bed before
the full 10-second count and could not hold against gravity, it meets the
criteria for score 2.
Question 8
During the assessment of Motor Leg strength (Item 5b), the right leg of a
supine patient is elevated to 30 degrees. The leg drifts down slowly but
does not touch the examination table or bed surface during the entire 5-
second countdown. What score should be recorded?
A. 0 – No drift
B. 1 – Drift; hits bed at end of 5 seconds or drifts without
touching
C. 2 – Some effort against gravity
D. 3 – No effort against gravity
Rationale: A score of 1 is given if the leg drifts during the 5-second
interval but does not completely hit the bed surface.
, Question 9
A clinician evaluates a patient for Limb Ataxia (Item 7). The patient
demonstrates clear, dysmetric tracking during the finger-to-nose test on
the right side. The left side is tested and shows perfectly smooth
tracking. The patient has no underlying motor weakness. What is the
final score?
A. 0 – Absent
B. 1 – Present in one limb
C. 2 – Present in two limbs
D. 1 – Present but unscoreable due to paralysis
Rationale: Ataxia must be out of proportion to any weakness. Since it is
cleanly present on one side (the right limb) and absent on the left, the
score is 1.
Question 10
When evaluating Sensory function (Item 8), a patient identifies pinprick
stimulation on the left arm and leg as feeling distinctly "duller" and less
sharp compared to the right side, but they still feel the touch. How
should this be scored?
A. 0 – Normal; no sensory loss
B. 1 – Mild-to-moderate sensory loss; patient feels pinprick as
less sharp
C. 2 – Severe to total sensory loss; patient is unaware of being touched
D. 1 – Total sensory loss limited to one dermatome
Rationale: A score of 1 represents mild-to-moderate sensory deficit
where the patient perceives the sensory input but notes a clear
qualitative reduction in sharpness or intensity.
Question 11
A patient is being assessed for Best Language (Item 9). When presented
with the standard NIHSS picture and description cards, the patient can
name several items but speaks with frequent word-substitution errors
and broken phrases, making it moderately difficult to grasp the overall
meaning. What score is appropriate?
A. 0 – No aphasia; normal
B. 1 – Mild-to-moderate aphasia; some obvious loss of fluency
or comprehension
C. 2 – Severe aphasia; all communication is through fragmentary
expression
D. 3 – Global aphasia; no usable speech or auditory comprehension
CERTIFICATION GROUP D
EXAM – 200 Q&A WITH
RATIONALES (VERIFIED)
NIH Stroke Scale (NIHSS) Certification Group D Examination
Question 1
A 64-year-old patient presents with an acute ischemic stroke. During the
initial assessment, the patient is fully awake, alert, and responds
immediately and appropriately to all verbal stimuli. How should the
clinician score Item 1a (Level of Consciousness)?
A. 1 – Not alert; arousable by minor stimulation
B. 0 – Alert; keenly responsive
C. 2 – Not alert; requires repeated stimulation to attend
D. 3 – Comatose; responds only with reflex motor or autonomic effects
Rationale: A score of 0 is correct because the patient is fully awake,
alert, and keenly responsive to environmental and verbal stimuli
without requiring any extra sensory stimulation.
Question 2
The clinician is assessing a patient’s Level of Consciousness Questions
(Item 1b). The patient is asked the current month and their current age.
The patient answers the month correctly but states their age incorrectly
by two years. What score should be assigned?
A. 0 – Answers both questions correctly
B. 1 – Answers one question correctly
C. 2 – Answers neither question correctly
D. 1 – Answers neither question correctly due to a language barrier
Rationale: Item 1b requires exact correctness. Since the patient
answered only one of the two questions accurately (the month), they
receive a score of 1. No partial credit is given for being close to the
correct age.
,Question 3
During the assessment of Item 1c (LOC Commands), a patient is
instructed to open and close their eyes, and then to grip and release their
non-paretic hand. The patient successfully opens and closes their eyes
but fails to respond to the hand grip command despite physical
demonstration. What is the correct score?
A. 0 – Performs both tasks correctly
B. 1 – Performs one task correctly
C. 2 – Performs neither task correctly
D. 1 – Patient attempted both but lacked physical strength
Rationale: The patient only completed one of the two distinct
commands successfully. Item 1c scores 0 for both correct, 1 for one
correct, and 2 for neither correct.
Question 4
A clinician evaluates a patient’s Best Gaze (Item 2). The patient exhibits
a partial gaze palsy where lateral eye movements are restricted in one
eye, but forced deviation is not present. The gaze deficit can be overcome
by voluntary tracking. What score is appropriate?
A. 0 – Normal
B. 1 – Partial gaze palsy; gaze is abnormal in one or both eyes
C. 2 – Forced deviation; total gaze paresis not overcome by the
oculocephalic maneuver
D. 1 – Total gaze paresis that resolves with blinking
Rationale: A partial gaze palsy is scored as a 1 when horizontal eye
movements are limited but total, fixed deviation is absent.
Question 5
When evaluating Visual Fields (Item 3) via confrontation, a patient
exhibits a clear and consistent quadrantanopia in the lower left visual
field. How should this finding be scored?
A. 0 – No visual loss
B. 1 – Partial hemianopia
C. 2 – Complete hemianopia
D. 3 – Bilateral hemianopia or blindness
Rationale: A quadrantanopia represents an asymmetric partial loss of
the visual field, which warrants a score of 1 under the NIHSS criteria.
Question 6
,A patient with an acute right-hemisphere stroke presents with a
complete flattening of the left nasolabial fold and an inability to smile or
clear air on the left side of the face. When looking at the upper face, the
patient can wrinkle their forehead and close both eyes tightly. What is
the correct score for Facial Palsy (Item 4)?
A. 0 – Normal symmetrical movements
B. 1 – Minor paralysis; flattened nasolabial fold
C. 2 – Partial paralysis; total or near-total paralysis of the
lower face
C. 3 – Complete paralysis of one or both sides; absence of facial
movement in upper and lower face
Rationale: Central facial weakness affecting the lower half of the face
completely or near-completely scales as a 2 (partial paralysis).
Question 7
The clinician tests the left arm for Motor Arm strength (Item 5a). The
patient lifts the left arm to 90 degrees while sitting, but the arm drifts
down and hits the bed at precisely 4 seconds. The patient cannot re-
elevate the limb against gravity. What is the correct score?
A. 1 – Drift; limb holds 90 degrees but drifts before 10 seconds
B. 2 – Some effort against gravity; limb cannot attain or
maintain 90 degrees
C. 3 – No effort against gravity; limb falls immediately
D. 4 – No movement at all
Rationale: Because the limb drifted down completely to the bed before
the full 10-second count and could not hold against gravity, it meets the
criteria for score 2.
Question 8
During the assessment of Motor Leg strength (Item 5b), the right leg of a
supine patient is elevated to 30 degrees. The leg drifts down slowly but
does not touch the examination table or bed surface during the entire 5-
second countdown. What score should be recorded?
A. 0 – No drift
B. 1 – Drift; hits bed at end of 5 seconds or drifts without
touching
C. 2 – Some effort against gravity
D. 3 – No effort against gravity
Rationale: A score of 1 is given if the leg drifts during the 5-second
interval but does not completely hit the bed surface.
, Question 9
A clinician evaluates a patient for Limb Ataxia (Item 7). The patient
demonstrates clear, dysmetric tracking during the finger-to-nose test on
the right side. The left side is tested and shows perfectly smooth
tracking. The patient has no underlying motor weakness. What is the
final score?
A. 0 – Absent
B. 1 – Present in one limb
C. 2 – Present in two limbs
D. 1 – Present but unscoreable due to paralysis
Rationale: Ataxia must be out of proportion to any weakness. Since it is
cleanly present on one side (the right limb) and absent on the left, the
score is 1.
Question 10
When evaluating Sensory function (Item 8), a patient identifies pinprick
stimulation on the left arm and leg as feeling distinctly "duller" and less
sharp compared to the right side, but they still feel the touch. How
should this be scored?
A. 0 – Normal; no sensory loss
B. 1 – Mild-to-moderate sensory loss; patient feels pinprick as
less sharp
C. 2 – Severe to total sensory loss; patient is unaware of being touched
D. 1 – Total sensory loss limited to one dermatome
Rationale: A score of 1 represents mild-to-moderate sensory deficit
where the patient perceives the sensory input but notes a clear
qualitative reduction in sharpness or intensity.
Question 11
A patient is being assessed for Best Language (Item 9). When presented
with the standard NIHSS picture and description cards, the patient can
name several items but speaks with frequent word-substitution errors
and broken phrases, making it moderately difficult to grasp the overall
meaning. What score is appropriate?
A. 0 – No aphasia; normal
B. 1 – Mild-to-moderate aphasia; some obvious loss of fluency
or comprehension
C. 2 – Severe aphasia; all communication is through fragmentary
expression
D. 3 – Global aphasia; no usable speech or auditory comprehension
