APEX NIH STROKE SCALE 300 ACTUAL QUESTIONS AND
SOLUTIONS (VERIFIED) WITH DETAILED RATIONALE NEW
UPDATE OF THIS YEAR ASSURRED PASS
This comprehensive question bank contains 300 multiple-choice questions
covering the APEX NIH Stroke Scale (NIHSS) certification content. It
systematically addresses all 11 components of the NIHSS, including Level of
Consciousness, Best Gaze, Visual Fields, Facial Palsy, Motor Arm, Motor Leg,
Limb Ataxia, Sensory, Best Language, Dysarthria, and Extinction and
Inattention. Each question includes the correct answer and a detailed
rationale explaining the clinical reasoning and scoring criteria. The questions
progress from foundational concepts to complex clinical scenarios, covering
scoring guidelines, administration techniques, and interpretation of results.
This resource supports effective exam preparation for healthcare
professionals seeking APEX NIHSS certification.
1. Which of the following statements regarding use of the NIH Stroke Scale is
TRUE?
A) It is useful to assess the severity of stroke.
B) It is not intended to determine the cause of stroke.
C) It was created for healthcare providers to facilitate early clinical diagnosis and
timely treatment of stroke patients.
D) All of the above.
Answer: D
Rationale: The NIH Stroke Scale is a comprehensive tool used to assess stroke
severity, but it is not designed to determine the underlying cause of the stroke. Its
primary purpose is to provide a standardized neurological examination for
healthcare providers to aid in diagnosis and treatment decisions .
2. How many components does the current NIH Stroke Scale consist of?
A) 8
B) 11
C) 15
D) 20
,Answer: B
Rationale: The current NIHSS consists of 11 components, a reduction from the
original 15. These components assess various neurological functions including
consciousness, motor strength, language, and sensory perception .
3. Which of the following is NOT one of the components of the NIH Stroke Scale?
A) Motor arm
B) Facial palsy
C) Blood pressure
D) Level of consciousness
Answer: C
Rationale: Blood pressure is not a component of the NIH Stroke Scale. The scale
assesses neurological function through 11 items including level of consciousness,
motor arm, and facial palsy, but vital signs like blood pressure are recorded
separately .
4. Which of the following statements about administering the NIH Stroke Scale is
correct?
A) Items should be assessed in any order convenient for the examiner.
B) The patient's performance can be rescored as the assessment progresses.
C) The patient should be coached during the exam to ensure best performance.
D) The score reflects how the patient performs the task, not how the provider
perceives the performance.
Answer: D
Rationale: The score is a reflection of how the patient performs the task or test, not
how the provider perceives the patient performing each test. Items should be
assessed in the order listed, and scores should not be changed as the assessment
progresses .
5. When assessing the Best Gaze component, what type of eye movement is tested?
A) Vertical gaze
B) Circular gaze
C) Diagonal gaze
D) Horizontal gaze
Answer: D
Rationale: For the Best Gaze component, only horizontal gaze is tested. This
includes both voluntary and reflexive eye movements. If the patient has a
conjugate deviation that can be overcome, the score is recorded as a 1 .
6. In the Motor Arm test, how long should the patient hold their arms extended?
,A) 5 seconds
B) 10 seconds
C) 15 seconds
D) 20 seconds
Answer: B
Rationale: When assessing motor arm function, the patient is instructed to hold
their arms extended for 10 seconds. If the patient is sitting, arms are held at 90
degrees; if lying down, they are extended at 45 degrees .
7. What does a score of UN mean in the NIH Stroke Scale?
A) Untestable
B) Uncertain
C) Unresponsive
D) Uncooperative
Answer: A
Rationale: A score of UN stands for "Untestable" and should be used only if there
is an amputation or joint fusion contributing to loss of function. The testing
provider should clearly document the reason for the UN score .
8. How is Best Language assessed in the NIH Stroke Scale?
A) By asking the patient to sing a song
B) By testing the patient's ability to write
C) By having the patient describe images and read words/sentences
D) By evaluating the patient's ability to understand complex instructions
Answer: C
Rationale: The patient is asked to describe what is happening in the images from
the NIH Stroke Scale manual and to read from the list of words and sentences
provided. If visual loss hinders the tests, the patient is asked to identify objects
placed in the hand .
9. What is the maximum score for the Extinction and Inattention component?
A) 1
B) 2
C) 3
D) 4
Answer: B
Rationale: The Extinction and Inattention (formerly neglect) component has a
maximum score of 2. A score of 0 indicates no abnormality, 1 indicates inattention
or extinction in one sensory modality, and 2 indicates profound inattention or
extinction in more than one modality .
, 10. How often are nurses in primary stroke centers required to be certified in the
NIH Stroke Scale?
A) Every 6 months
B) Annually
C) Every 2 years
D) Every 5 years
Answer: C
Rationale: Nurses in primary stroke centers are typically required to be certified in
the NIH Stroke Scale every 2 years. This ensures that healthcare providers
maintain competency in stroke assessment .
11. Skilled and consistent use of a Standardized Nursing Assessment such as
NIHSS may:
A) Positively impact patient outcomes
B) Lead to early intervention
C) Contribute to a better prognosis
D) Limit the extension of neurological damage
E) All of the above
Answer: E
Rationale: The NIHSS is a standardized assessment tool that, when used
consistently, can positively impact patient outcomes by enabling early intervention,
contributing to better prognosis, and potentially limiting the extension of
neurological damage .
12. Performing an NIHSS on a patient, once the nurse is familiar with it:
A) Should take 10 minutes or so to complete
B) Should take about an hour if the patient cooperates
C) Only needs to be done upon admission and again on discharge
D) Will show poor sensitivity to neurological change and Glasgow Coma Scale
should be used instead
Answer: A
Rationale: Once familiar with the NIHSS, a nurse can typically complete the
assessment in approximately 10 minutes. It is a relatively quick yet comprehensive
neurological examination .
13. When should NIHSS results be communicated?
A) When you notice a neurological decline
B) When a new deficit has arisen
C) When an already present deficit has gotten worse
SOLUTIONS (VERIFIED) WITH DETAILED RATIONALE NEW
UPDATE OF THIS YEAR ASSURRED PASS
This comprehensive question bank contains 300 multiple-choice questions
covering the APEX NIH Stroke Scale (NIHSS) certification content. It
systematically addresses all 11 components of the NIHSS, including Level of
Consciousness, Best Gaze, Visual Fields, Facial Palsy, Motor Arm, Motor Leg,
Limb Ataxia, Sensory, Best Language, Dysarthria, and Extinction and
Inattention. Each question includes the correct answer and a detailed
rationale explaining the clinical reasoning and scoring criteria. The questions
progress from foundational concepts to complex clinical scenarios, covering
scoring guidelines, administration techniques, and interpretation of results.
This resource supports effective exam preparation for healthcare
professionals seeking APEX NIHSS certification.
1. Which of the following statements regarding use of the NIH Stroke Scale is
TRUE?
A) It is useful to assess the severity of stroke.
B) It is not intended to determine the cause of stroke.
C) It was created for healthcare providers to facilitate early clinical diagnosis and
timely treatment of stroke patients.
D) All of the above.
Answer: D
Rationale: The NIH Stroke Scale is a comprehensive tool used to assess stroke
severity, but it is not designed to determine the underlying cause of the stroke. Its
primary purpose is to provide a standardized neurological examination for
healthcare providers to aid in diagnosis and treatment decisions .
2. How many components does the current NIH Stroke Scale consist of?
A) 8
B) 11
C) 15
D) 20
,Answer: B
Rationale: The current NIHSS consists of 11 components, a reduction from the
original 15. These components assess various neurological functions including
consciousness, motor strength, language, and sensory perception .
3. Which of the following is NOT one of the components of the NIH Stroke Scale?
A) Motor arm
B) Facial palsy
C) Blood pressure
D) Level of consciousness
Answer: C
Rationale: Blood pressure is not a component of the NIH Stroke Scale. The scale
assesses neurological function through 11 items including level of consciousness,
motor arm, and facial palsy, but vital signs like blood pressure are recorded
separately .
4. Which of the following statements about administering the NIH Stroke Scale is
correct?
A) Items should be assessed in any order convenient for the examiner.
B) The patient's performance can be rescored as the assessment progresses.
C) The patient should be coached during the exam to ensure best performance.
D) The score reflects how the patient performs the task, not how the provider
perceives the performance.
Answer: D
Rationale: The score is a reflection of how the patient performs the task or test, not
how the provider perceives the patient performing each test. Items should be
assessed in the order listed, and scores should not be changed as the assessment
progresses .
5. When assessing the Best Gaze component, what type of eye movement is tested?
A) Vertical gaze
B) Circular gaze
C) Diagonal gaze
D) Horizontal gaze
Answer: D
Rationale: For the Best Gaze component, only horizontal gaze is tested. This
includes both voluntary and reflexive eye movements. If the patient has a
conjugate deviation that can be overcome, the score is recorded as a 1 .
6. In the Motor Arm test, how long should the patient hold their arms extended?
,A) 5 seconds
B) 10 seconds
C) 15 seconds
D) 20 seconds
Answer: B
Rationale: When assessing motor arm function, the patient is instructed to hold
their arms extended for 10 seconds. If the patient is sitting, arms are held at 90
degrees; if lying down, they are extended at 45 degrees .
7. What does a score of UN mean in the NIH Stroke Scale?
A) Untestable
B) Uncertain
C) Unresponsive
D) Uncooperative
Answer: A
Rationale: A score of UN stands for "Untestable" and should be used only if there
is an amputation or joint fusion contributing to loss of function. The testing
provider should clearly document the reason for the UN score .
8. How is Best Language assessed in the NIH Stroke Scale?
A) By asking the patient to sing a song
B) By testing the patient's ability to write
C) By having the patient describe images and read words/sentences
D) By evaluating the patient's ability to understand complex instructions
Answer: C
Rationale: The patient is asked to describe what is happening in the images from
the NIH Stroke Scale manual and to read from the list of words and sentences
provided. If visual loss hinders the tests, the patient is asked to identify objects
placed in the hand .
9. What is the maximum score for the Extinction and Inattention component?
A) 1
B) 2
C) 3
D) 4
Answer: B
Rationale: The Extinction and Inattention (formerly neglect) component has a
maximum score of 2. A score of 0 indicates no abnormality, 1 indicates inattention
or extinction in one sensory modality, and 2 indicates profound inattention or
extinction in more than one modality .
, 10. How often are nurses in primary stroke centers required to be certified in the
NIH Stroke Scale?
A) Every 6 months
B) Annually
C) Every 2 years
D) Every 5 years
Answer: C
Rationale: Nurses in primary stroke centers are typically required to be certified in
the NIH Stroke Scale every 2 years. This ensures that healthcare providers
maintain competency in stroke assessment .
11. Skilled and consistent use of a Standardized Nursing Assessment such as
NIHSS may:
A) Positively impact patient outcomes
B) Lead to early intervention
C) Contribute to a better prognosis
D) Limit the extension of neurological damage
E) All of the above
Answer: E
Rationale: The NIHSS is a standardized assessment tool that, when used
consistently, can positively impact patient outcomes by enabling early intervention,
contributing to better prognosis, and potentially limiting the extension of
neurological damage .
12. Performing an NIHSS on a patient, once the nurse is familiar with it:
A) Should take 10 minutes or so to complete
B) Should take about an hour if the patient cooperates
C) Only needs to be done upon admission and again on discharge
D) Will show poor sensitivity to neurological change and Glasgow Coma Scale
should be used instead
Answer: A
Rationale: Once familiar with the NIHSS, a nurse can typically complete the
assessment in approximately 10 minutes. It is a relatively quick yet comprehensive
neurological examination .
13. When should NIHSS results be communicated?
A) When you notice a neurological decline
B) When a new deficit has arisen
C) When an already present deficit has gotten worse
