NIH Stroke Scale (NIHSS) Group D Certification
Test Comprehensive Patient 1-6 Scoring Guide
EXAM OVERVIEW
Core Domains Covered:
• General NIHSS Knowledge & Administration
• Patient 1-6 Detailed Scoring Scenarios
• Item-by-Item Scoring Criteria
• Clinical Decision-Making in Stroke Assessment
• Common Scoring Pitfalls
• Certification-Level Clinical Vignettes
SECTION 1: GENERAL NIHSS KNOWLEDGE (Questions 1-20)
1. The NIH Stroke Scale was originally developed for which primary
purpose?
• A) To predict long-term disability outcomes
• B) To provide a standardized, reproducible measure of stroke severity
in clinical trials
• C) To determine the need for mechanical ventilation
• D) To assess cognitive function in stroke patients
Rationale: The NIHSS was developed in the 1980s as a standardized tool for
clinical trials to ensure consistent measurement of neurological deficits. Its use has
since expanded to clinical practice.
2. The maximum score on the NIH Stroke Scale is:
, • A) 42
• B) 36
• C) 24
• D) 15
Rationale: The NIHSS has 15 items (with subparts for motor arms and legs) and a
maximum total score of 42. The score correlates with stroke severity: 0 = no
stroke, 1-4 = minor, 5-15 = moderate, 16-20 = moderate-severe, 21-42 = severe.
3. A score of 0 on the NIHSS indicates:
• A) The patient is deceased
• B) No stroke-related neurological deficits
• C) The patient is in a coma
• D) The patient has mild aphasia
Rationale: A score of 0 indicates the patient has no measurable stroke-related
neurological deficits. This does not necessarily mean the patient is "normal" in all
aspects, but that stroke-specific items are not impaired.
4. Which item on the NIHSS carries the highest possible point value?
• A) Level of Consciousness
• B) Best Language
• C) Motor Arm and Motor Leg (combined)
• D) Sensory
Rationale: The Motor Arm and Motor Leg items each have a maximum score of 4
points per limb, totaling 8 points across both limbs. The combined motor
component is the highest-weighted section of the NIHSS.
5. The NIHSS should ideally be completed within what timeframe after
patient arrival?
, • A) 5 minutes
• B) 10 minutes
• C) 20 minutes
• D) 30 minutes
Rationale: The NIHSS is designed to be completed in approximately 6-10
minutes. Efficient administration is important to avoid delaying acute stroke
treatments like thrombolytics.
6. A patient who cannot respond verbally due to intubation or tracheostomy
should be scored as:
• A) Automatic 2 on all verbal items
• B) Scored based on the examiner's best assessment of responses
• C) Excluded from NIHSS scoring
• D) Given a score of 0 on language items
Rationale: For intubated patients, the examiner should attempt to evaluate
responses through writing, gestures, or other non-verbal means. The items should
be scored to the best of the examiner's ability.
7. Which of the following is NOT assessed by the NIHSS?
• A) Level of consciousness
• B) Pupillary light reflex
• C) Motor function
• D) Sensory function
Rationale: Pupillary light reflex is not part of the NIHSS. The NIHSS includes:
LOC, gaze, visual fields, facial palsy, motor arm/leg, limb ataxia, sensory,
language, dysarthria, and extinction/inattention.
8. Item 1a (Level of Consciousness) is scored from:
, • A) 0-2
• B) 0-3
• C) 0-4
• D) 0-5
Rationale: LOC is scored 0-3: 0 = alert, 1 = not alert but arousable, 2 =
obtunded/repeated stimulation needed, 3 = unresponsive or reflex-only responses.
9. The NIHSS is most reliable when performed by:
• A) Any healthcare provider
• B) Only neurologists
• C) Trained and certified examiners
• D) Only the attending physician
Rationale: Proper training and certification significantly improve inter-rater
reliability. Many institutions require NIHSS certification for nurses and physicians
who care for stroke patients.
10. A patient who does not follow commands but withdraws purposefully
from painful stimulation scores what on item 1a?
• A) 0
• B) 1
• C) 2
• D) 3
Rationale: Item 1a scoring: 0 = alert, 1 = not alert but arousable by minor
stimulation, 2 = requires repeated stimulation or obtunded, 3 = unresponsive or
only reflex movements. Purposeful withdrawal indicates some responsiveness.
11. Which item is scored FIRST in the NIHSS?
Test Comprehensive Patient 1-6 Scoring Guide
EXAM OVERVIEW
Core Domains Covered:
• General NIHSS Knowledge & Administration
• Patient 1-6 Detailed Scoring Scenarios
• Item-by-Item Scoring Criteria
• Clinical Decision-Making in Stroke Assessment
• Common Scoring Pitfalls
• Certification-Level Clinical Vignettes
SECTION 1: GENERAL NIHSS KNOWLEDGE (Questions 1-20)
1. The NIH Stroke Scale was originally developed for which primary
purpose?
• A) To predict long-term disability outcomes
• B) To provide a standardized, reproducible measure of stroke severity
in clinical trials
• C) To determine the need for mechanical ventilation
• D) To assess cognitive function in stroke patients
Rationale: The NIHSS was developed in the 1980s as a standardized tool for
clinical trials to ensure consistent measurement of neurological deficits. Its use has
since expanded to clinical practice.
2. The maximum score on the NIH Stroke Scale is:
, • A) 42
• B) 36
• C) 24
• D) 15
Rationale: The NIHSS has 15 items (with subparts for motor arms and legs) and a
maximum total score of 42. The score correlates with stroke severity: 0 = no
stroke, 1-4 = minor, 5-15 = moderate, 16-20 = moderate-severe, 21-42 = severe.
3. A score of 0 on the NIHSS indicates:
• A) The patient is deceased
• B) No stroke-related neurological deficits
• C) The patient is in a coma
• D) The patient has mild aphasia
Rationale: A score of 0 indicates the patient has no measurable stroke-related
neurological deficits. This does not necessarily mean the patient is "normal" in all
aspects, but that stroke-specific items are not impaired.
4. Which item on the NIHSS carries the highest possible point value?
• A) Level of Consciousness
• B) Best Language
• C) Motor Arm and Motor Leg (combined)
• D) Sensory
Rationale: The Motor Arm and Motor Leg items each have a maximum score of 4
points per limb, totaling 8 points across both limbs. The combined motor
component is the highest-weighted section of the NIHSS.
5. The NIHSS should ideally be completed within what timeframe after
patient arrival?
, • A) 5 minutes
• B) 10 minutes
• C) 20 minutes
• D) 30 minutes
Rationale: The NIHSS is designed to be completed in approximately 6-10
minutes. Efficient administration is important to avoid delaying acute stroke
treatments like thrombolytics.
6. A patient who cannot respond verbally due to intubation or tracheostomy
should be scored as:
• A) Automatic 2 on all verbal items
• B) Scored based on the examiner's best assessment of responses
• C) Excluded from NIHSS scoring
• D) Given a score of 0 on language items
Rationale: For intubated patients, the examiner should attempt to evaluate
responses through writing, gestures, or other non-verbal means. The items should
be scored to the best of the examiner's ability.
7. Which of the following is NOT assessed by the NIHSS?
• A) Level of consciousness
• B) Pupillary light reflex
• C) Motor function
• D) Sensory function
Rationale: Pupillary light reflex is not part of the NIHSS. The NIHSS includes:
LOC, gaze, visual fields, facial palsy, motor arm/leg, limb ataxia, sensory,
language, dysarthria, and extinction/inattention.
8. Item 1a (Level of Consciousness) is scored from:
, • A) 0-2
• B) 0-3
• C) 0-4
• D) 0-5
Rationale: LOC is scored 0-3: 0 = alert, 1 = not alert but arousable, 2 =
obtunded/repeated stimulation needed, 3 = unresponsive or reflex-only responses.
9. The NIHSS is most reliable when performed by:
• A) Any healthcare provider
• B) Only neurologists
• C) Trained and certified examiners
• D) Only the attending physician
Rationale: Proper training and certification significantly improve inter-rater
reliability. Many institutions require NIHSS certification for nurses and physicians
who care for stroke patients.
10. A patient who does not follow commands but withdraws purposefully
from painful stimulation scores what on item 1a?
• A) 0
• B) 1
• C) 2
• D) 3
Rationale: Item 1a scoring: 0 = alert, 1 = not alert but arousable by minor
stimulation, 2 = requires repeated stimulation or obtunded, 3 = unresponsive or
only reflex movements. Purposeful withdrawal indicates some responsiveness.
11. Which item is scored FIRST in the NIHSS?
