2026 NIH Stroke Scale (NIHSS) Certification: Answer Key for
Test Groups A-F (Patients 1-6) | 100% Verified A+ Guide - 200
Questions
This exam assesses advanced understanding of the Level of Consciousness (LOC) component of the NIH Stroke
Scale (NIHSS). Questions cover the LOC items (1a, 1b, 1c), scoring nuances, distinctions between consciousness
and cognitive deficits, and application to complex clinical scenarios. Designed for US university graduate-level
neuroscience or neurology courses. It contains 200 multiple-choice questions, each with four distractors and a
fully worked rationale that explains why the keyed answer is correct. Content is organized into 11 focused
sections: Level of Consciousness, Best Gaze, Visual Fields, Facial Palsy, Motor Arm, Motor Leg, Limb Ataxia,
Sensory, Best Language, Dysarthria, Extinction and Inattention. Targeted learning outcomes include: Accurately
score NIHSS LOC items (1a, 1b, 1c) in varied clinical presentations.; Differentiate between reduced
consciousness, aphasia, and dysarthria in scoring.; Apply the NIHSS LOC scoring rules to patients with language
barriers, intubation, or sedation.; Analyze the impact of LOC score on overall NIHSS and clinical
decision-making.. Every item has been reviewed for clinical accuracy, current guidelines, and clarity so that
students can study with confidence and self-correct as they work through the bank. Use it as a high-yield review
immediately before the exam, or as a structured practice tool during the unit - the rationales double as concise
teaching notes. The recommended writing time is 3 hours, with a passing score of 90% (A+ grade). Aligned with
Meets US university standards for advanced neuroscience and clinical neurology coursework, aligned with
Section 1: Level of Consciousness (Questions 1-19)
1 A patient with acute ischemic stroke is drowsy but rouses to voice and
follows commands intermittently. When asked to open and close eyes, they
do so correctly 3 out of 5 times. What is the correct NIHSS LOC 1a score?
A) 0 (Alert)
B) 1 (Not alert, but arousable by minor stimulation)
C) 2 (Not alert, requires repeated stimulation to attend)
D) 3 (Responds only with reflex motor or autonomic effects)
Answer: B
Rationale: The patient is drowsy but rouses to voice (minor stimulation) and
intermittently follows commands, meeting the definition of 'not alert, but
arousable by minor stimulation' for a score of 1. Score 0 requires full alertness;
score 2 requires repeated or painful stimulation; score 3 is for no response
except reflexes.
2 A patient with global aphasia cannot answer any questions or follow
commands. The examiner notes that the patient spontaneously opens eyes
and looks around. What is the correct NIHSS LOC 1a score?
A) 0 (Alert)
B) 1 (Not alert, but arousable by minor stimulation)
,C) 2 (Not alert, requires repeated stimulation to attend)
D) 3 (Responds only with reflex motor or autonomic effects)
Answer: A
Rationale: LOC 1a assesses consciousness, not language. The patient is alert
(spontaneous eye opening, looking around) despite global aphasia. Score 0
applies because the patient is not drowsy or obtunded. Aphasia does not lower
the LOC score; it is captured separately in the language item.
3 For NIHSS item 1b (LOC questions), which of the following best describes
the correct administration and scoring when a patient has a language barrier?
A) Use an interpreter if available; score 0 if correct, 1 if incorrect, 2 if unable
to answer due to barrier.
B) Score 0 if the patient nods or shakes head appropriately to the questions.
C) Score 2 if the patient cannot answer due to language barrier, as this
indicates severe deficit.
D) Administer in English only; if no response, score 2.
Answer: A
Rationale: The NIHSS instructs to use an interpreter if available for patients
with language barriers. If the patient answers correctly via interpreter, score 0;
if incorrect, score 1; if unable to answer (e.g., no interpreter), score 2. Option B
is incorrect because nodding/shaking is not a reliable substitute for verbal
response in item 1b. Option C is wrong because the score of 2 is reserved for
inability to answer due to reduced consciousness or aphasia, not language
barrier per se. Option D is incorrect as it disregards the accommodation for
language.
4 A patient is intubated and sedated for airway protection. The NIHSS is being
performed. For item 1c (LOC commands), the patient does not open or close
eyes on command. What is the appropriate score?
A) 0 (Performs both tasks correctly)
B) 1 (Performs one task correctly)
C) 2 (Performs neither task correctly)
D) Untestable due to intubation; score should be omitted.
Answer: C
Rationale: Per NIHSS guidelines, intubation does not exempt the patient from
scoring. If the patient cannot perform any command due to sedation or other
,factors, a score of 2 is given. The commands are standardized (open/close eyes,
grip/release hand). Option D is incorrect because the NIHSS does not allow
omission of items; a score must be assigned based on the patient's response.
5 A patient with a brainstem stroke has locked-in syndrome: fully conscious
but unable to move or speak except for vertical eye movements. What is the
correct NIHSS LOC 1a score?
A) 0 (Alert)
B) 1 (Not alert, but arousable by minor stimulation)
C) 2 (Not alert, requires repeated stimulation to attend)
D) 3 (Responds only with reflex motor or autonomic effects)
Answer: A
Rationale: Locked-in syndrome patients are fully conscious (alert) despite
paralysis. The LOC score is based on arousal and awareness, not motor ability.
Because the patient is awake and aware, score 0 is correct. The motor deficits
are captured in other NIHSS items.
6 When scoring NIHSS item 1b (LOC questions), a patient with aphasia
answers the month question incorrectly but the age question correctly. What
is the score?
A) 0 (Both correct)
B) 1 (One correct, one incorrect)
C) 2 (Both incorrect or unable to answer)
D) 1 (One correct, one incorrect) only if the incorrect answer is due to
aphasia; otherwise 2.
Answer: B
Rationale: Scoring for item 1b is based on the number of correct answers
regardless of the cause. One correct and one incorrect yields a score of 1.
Aphasia does not alter scoring; if the patient cannot answer due to aphasia, it is
scored as incorrect. Option D is incorrect because the NIHSS does not
differentiate cause for item 1b.
7 A patient is drowsy but opens eyes to painful stimulus and withdraws from
pain. They do not follow commands. What is the correct LOC 1a score?
A) 0 (Alert)
B) 1 (Not alert, but arousable by minor stimulation)
, C) 2 (Not alert, requires repeated stimulation to attend)
D) 3 (Responds only with reflex motor or autonomic effects)
Answer: C
Rationale: The patient requires painful stimulation to arouse, which is 'repeated
or painful stimulation' for a score of 2. Minor stimulation (voice or light touch)
is insufficient. Withdrawal from pain is a purposeful response, not reflex, so
score 3 (reflex only) is incorrect. Score 1 is for arousal by minor stimulation.
8 For NIHSS item 1c, which of the following is true regarding the use of
alternative commands for patients with aphasia?
A) Alternative commands such as 'stick out your tongue' are acceptable if the
patient cannot perform the standard commands.
B) Only the standard commands (open/close eyes, grip/release) should be
used; no alternatives.
C) If the patient cannot perform the standard commands, score 2
automatically.
D) Commands can be mimed if the patient does not understand verbal
instructions.
Answer: B
Rationale: The NIHSS specifies that only the two standardized commands
(open/close eyes, grip/release non-paretic hand) are to be used. No alternatives
are permitted. If the patient cannot perform them due to aphasia or other
deficit, score 2. Mimed commands are not allowed as they test comprehension
differently.
9 A patient is found to have a Glasgow Coma Scale (GCS) of 14 (E4 V4 M6).
Which NIHSS LOC 1a score is most likely?
A) 0 (Alert)
B) 1 (Not alert, but arousable by minor stimulation)
C) 2 (Not alert, requires repeated stimulation to attend)
D) 3 (Responds only with reflex motor or autonomic effects)
Answer: A
Rationale: A GCS of 14 indicates a patient who is alert or nearly alert (E4 =
spontaneous eye opening, V4 = confused but verbal, M6 = obeys commands).
This corresponds to an NIHSS LOC 1a score of 0 (alert). Score 1 would be
associated with GCS 13-14 with some drowsiness, but GCS 14 with obeying
Test Groups A-F (Patients 1-6) | 100% Verified A+ Guide - 200
Questions
This exam assesses advanced understanding of the Level of Consciousness (LOC) component of the NIH Stroke
Scale (NIHSS). Questions cover the LOC items (1a, 1b, 1c), scoring nuances, distinctions between consciousness
and cognitive deficits, and application to complex clinical scenarios. Designed for US university graduate-level
neuroscience or neurology courses. It contains 200 multiple-choice questions, each with four distractors and a
fully worked rationale that explains why the keyed answer is correct. Content is organized into 11 focused
sections: Level of Consciousness, Best Gaze, Visual Fields, Facial Palsy, Motor Arm, Motor Leg, Limb Ataxia,
Sensory, Best Language, Dysarthria, Extinction and Inattention. Targeted learning outcomes include: Accurately
score NIHSS LOC items (1a, 1b, 1c) in varied clinical presentations.; Differentiate between reduced
consciousness, aphasia, and dysarthria in scoring.; Apply the NIHSS LOC scoring rules to patients with language
barriers, intubation, or sedation.; Analyze the impact of LOC score on overall NIHSS and clinical
decision-making.. Every item has been reviewed for clinical accuracy, current guidelines, and clarity so that
students can study with confidence and self-correct as they work through the bank. Use it as a high-yield review
immediately before the exam, or as a structured practice tool during the unit - the rationales double as concise
teaching notes. The recommended writing time is 3 hours, with a passing score of 90% (A+ grade). Aligned with
Meets US university standards for advanced neuroscience and clinical neurology coursework, aligned with
Section 1: Level of Consciousness (Questions 1-19)
1 A patient with acute ischemic stroke is drowsy but rouses to voice and
follows commands intermittently. When asked to open and close eyes, they
do so correctly 3 out of 5 times. What is the correct NIHSS LOC 1a score?
A) 0 (Alert)
B) 1 (Not alert, but arousable by minor stimulation)
C) 2 (Not alert, requires repeated stimulation to attend)
D) 3 (Responds only with reflex motor or autonomic effects)
Answer: B
Rationale: The patient is drowsy but rouses to voice (minor stimulation) and
intermittently follows commands, meeting the definition of 'not alert, but
arousable by minor stimulation' for a score of 1. Score 0 requires full alertness;
score 2 requires repeated or painful stimulation; score 3 is for no response
except reflexes.
2 A patient with global aphasia cannot answer any questions or follow
commands. The examiner notes that the patient spontaneously opens eyes
and looks around. What is the correct NIHSS LOC 1a score?
A) 0 (Alert)
B) 1 (Not alert, but arousable by minor stimulation)
,C) 2 (Not alert, requires repeated stimulation to attend)
D) 3 (Responds only with reflex motor or autonomic effects)
Answer: A
Rationale: LOC 1a assesses consciousness, not language. The patient is alert
(spontaneous eye opening, looking around) despite global aphasia. Score 0
applies because the patient is not drowsy or obtunded. Aphasia does not lower
the LOC score; it is captured separately in the language item.
3 For NIHSS item 1b (LOC questions), which of the following best describes
the correct administration and scoring when a patient has a language barrier?
A) Use an interpreter if available; score 0 if correct, 1 if incorrect, 2 if unable
to answer due to barrier.
B) Score 0 if the patient nods or shakes head appropriately to the questions.
C) Score 2 if the patient cannot answer due to language barrier, as this
indicates severe deficit.
D) Administer in English only; if no response, score 2.
Answer: A
Rationale: The NIHSS instructs to use an interpreter if available for patients
with language barriers. If the patient answers correctly via interpreter, score 0;
if incorrect, score 1; if unable to answer (e.g., no interpreter), score 2. Option B
is incorrect because nodding/shaking is not a reliable substitute for verbal
response in item 1b. Option C is wrong because the score of 2 is reserved for
inability to answer due to reduced consciousness or aphasia, not language
barrier per se. Option D is incorrect as it disregards the accommodation for
language.
4 A patient is intubated and sedated for airway protection. The NIHSS is being
performed. For item 1c (LOC commands), the patient does not open or close
eyes on command. What is the appropriate score?
A) 0 (Performs both tasks correctly)
B) 1 (Performs one task correctly)
C) 2 (Performs neither task correctly)
D) Untestable due to intubation; score should be omitted.
Answer: C
Rationale: Per NIHSS guidelines, intubation does not exempt the patient from
scoring. If the patient cannot perform any command due to sedation or other
,factors, a score of 2 is given. The commands are standardized (open/close eyes,
grip/release hand). Option D is incorrect because the NIHSS does not allow
omission of items; a score must be assigned based on the patient's response.
5 A patient with a brainstem stroke has locked-in syndrome: fully conscious
but unable to move or speak except for vertical eye movements. What is the
correct NIHSS LOC 1a score?
A) 0 (Alert)
B) 1 (Not alert, but arousable by minor stimulation)
C) 2 (Not alert, requires repeated stimulation to attend)
D) 3 (Responds only with reflex motor or autonomic effects)
Answer: A
Rationale: Locked-in syndrome patients are fully conscious (alert) despite
paralysis. The LOC score is based on arousal and awareness, not motor ability.
Because the patient is awake and aware, score 0 is correct. The motor deficits
are captured in other NIHSS items.
6 When scoring NIHSS item 1b (LOC questions), a patient with aphasia
answers the month question incorrectly but the age question correctly. What
is the score?
A) 0 (Both correct)
B) 1 (One correct, one incorrect)
C) 2 (Both incorrect or unable to answer)
D) 1 (One correct, one incorrect) only if the incorrect answer is due to
aphasia; otherwise 2.
Answer: B
Rationale: Scoring for item 1b is based on the number of correct answers
regardless of the cause. One correct and one incorrect yields a score of 1.
Aphasia does not alter scoring; if the patient cannot answer due to aphasia, it is
scored as incorrect. Option D is incorrect because the NIHSS does not
differentiate cause for item 1b.
7 A patient is drowsy but opens eyes to painful stimulus and withdraws from
pain. They do not follow commands. What is the correct LOC 1a score?
A) 0 (Alert)
B) 1 (Not alert, but arousable by minor stimulation)
, C) 2 (Not alert, requires repeated stimulation to attend)
D) 3 (Responds only with reflex motor or autonomic effects)
Answer: C
Rationale: The patient requires painful stimulation to arouse, which is 'repeated
or painful stimulation' for a score of 2. Minor stimulation (voice or light touch)
is insufficient. Withdrawal from pain is a purposeful response, not reflex, so
score 3 (reflex only) is incorrect. Score 1 is for arousal by minor stimulation.
8 For NIHSS item 1c, which of the following is true regarding the use of
alternative commands for patients with aphasia?
A) Alternative commands such as 'stick out your tongue' are acceptable if the
patient cannot perform the standard commands.
B) Only the standard commands (open/close eyes, grip/release) should be
used; no alternatives.
C) If the patient cannot perform the standard commands, score 2
automatically.
D) Commands can be mimed if the patient does not understand verbal
instructions.
Answer: B
Rationale: The NIHSS specifies that only the two standardized commands
(open/close eyes, grip/release non-paretic hand) are to be used. No alternatives
are permitted. If the patient cannot perform them due to aphasia or other
deficit, score 2. Mimed commands are not allowed as they test comprehension
differently.
9 A patient is found to have a Glasgow Coma Scale (GCS) of 14 (E4 V4 M6).
Which NIHSS LOC 1a score is most likely?
A) 0 (Alert)
B) 1 (Not alert, but arousable by minor stimulation)
C) 2 (Not alert, requires repeated stimulation to attend)
D) 3 (Responds only with reflex motor or autonomic effects)
Answer: A
Rationale: A GCS of 14 indicates a patient who is alert or nearly alert (E4 =
spontaneous eye opening, V4 = confused but verbal, M6 = obeys commands).
This corresponds to an NIHSS LOC 1a score of 0 (alert). Score 1 would be
associated with GCS 13-14 with some drowsiness, but GCS 14 with obeying
