2026 NIH Stroke Scale (NIHSS)
Comprehensive Practice Examination
Original Practice Exam — Groups A–F | Patients 1–6 | 60 Questions + Detailed
Answer Key
Important: This is an original practice examination, not a reproduction of proprietary APEX
assessment questions, patient videos, or a confidential 2026/2027 test bank. The scoring
scenarios are designed to train the same NIHSS concepts and decision-making skills. The NIHSS
ranges from 0–42 and evaluates consciousness, gaze, vision, facial movement, motor function,
ataxia, sensation, language, dysarthria, and neglect.
The 2026 AHA/ASA acute ischemic stroke guideline continues to recognize NIHSS as an
important component of acute stroke assessment, while emphasizing that treatment decisions
should not be based on the NIHSS number alone.
EXAM INSTRUCTIONS
Choose the single best answer unless otherwise indicated.
For scoring questions:
1. Determine the patient's actual observed performance.
2. Do not give credit for an ability the patient does not demonstrate.
3. Follow the NIHSS sequence.
4. Do not coach the patient.
, 5. Remember that Item 9 (Best Language) is scored according to the patient's best
language performance, whereas several other items emphasize the first response.
GROUP A — PATIENTS 1–6
Patient 1 — Mild Right Hemiparesis
A 67-year-old patient suddenly develops right facial weakness and right arm weakness. The
patient is awake and immediately answers the month and age correctly. They follow both
commands.
Findings:
• Alert and responsive
• Month and age correct
• Both commands performed
• Horizontal gaze normal
• Visual fields intact
• Minor right facial weakness
• Left arm: no drift
• Right arm: drifts but does not hit the bed
• Both legs: no drift
• No limb ataxia
• Sensation normal
• Language normal
• Speech slightly slurred
• No extinction
Question 1
Which NIHSS component is primarily responsible for the patient's motor deficit?
A. Item 4
B. Item 5
C. Item 6
D. Item 7
Answer: B. Item 5
Rationale: Item 5 evaluates motor function of the left and right arms. Item 6 evaluates the legs.
, Question 2
The right arm drifts but does not contact the bed. What motor-arm score should be assigned?
A. 0
B. 1
C. 2
D. 3
Answer: B. 1
Rationale: Drift without the arm reaching the bed corresponds to a motor-arm score of 1.
Question 3
The patient has minor right facial weakness with asymmetry on smiling but otherwise normal
facial movement. What is the most appropriate facial-palsy score?
A. 0
B. 1
C. 2
D. 3
Answer: B. 1
Question 4
Which finding would increase the patient's NIHSS score without necessarily changing the motor-
arm score?
A. Normal sensation
B. Mild dysarthria
C. Normal visual fields
D. Correct age response
Answer: B. Mild dysarthria
Question 5
Which principle should the examiner follow?
Comprehensive Practice Examination
Original Practice Exam — Groups A–F | Patients 1–6 | 60 Questions + Detailed
Answer Key
Important: This is an original practice examination, not a reproduction of proprietary APEX
assessment questions, patient videos, or a confidential 2026/2027 test bank. The scoring
scenarios are designed to train the same NIHSS concepts and decision-making skills. The NIHSS
ranges from 0–42 and evaluates consciousness, gaze, vision, facial movement, motor function,
ataxia, sensation, language, dysarthria, and neglect.
The 2026 AHA/ASA acute ischemic stroke guideline continues to recognize NIHSS as an
important component of acute stroke assessment, while emphasizing that treatment decisions
should not be based on the NIHSS number alone.
EXAM INSTRUCTIONS
Choose the single best answer unless otherwise indicated.
For scoring questions:
1. Determine the patient's actual observed performance.
2. Do not give credit for an ability the patient does not demonstrate.
3. Follow the NIHSS sequence.
4. Do not coach the patient.
, 5. Remember that Item 9 (Best Language) is scored according to the patient's best
language performance, whereas several other items emphasize the first response.
GROUP A — PATIENTS 1–6
Patient 1 — Mild Right Hemiparesis
A 67-year-old patient suddenly develops right facial weakness and right arm weakness. The
patient is awake and immediately answers the month and age correctly. They follow both
commands.
Findings:
• Alert and responsive
• Month and age correct
• Both commands performed
• Horizontal gaze normal
• Visual fields intact
• Minor right facial weakness
• Left arm: no drift
• Right arm: drifts but does not hit the bed
• Both legs: no drift
• No limb ataxia
• Sensation normal
• Language normal
• Speech slightly slurred
• No extinction
Question 1
Which NIHSS component is primarily responsible for the patient's motor deficit?
A. Item 4
B. Item 5
C. Item 6
D. Item 7
Answer: B. Item 5
Rationale: Item 5 evaluates motor function of the left and right arms. Item 6 evaluates the legs.
, Question 2
The right arm drifts but does not contact the bed. What motor-arm score should be assigned?
A. 0
B. 1
C. 2
D. 3
Answer: B. 1
Rationale: Drift without the arm reaching the bed corresponds to a motor-arm score of 1.
Question 3
The patient has minor right facial weakness with asymmetry on smiling but otherwise normal
facial movement. What is the most appropriate facial-palsy score?
A. 0
B. 1
C. 2
D. 3
Answer: B. 1
Question 4
Which finding would increase the patient's NIHSS score without necessarily changing the motor-
arm score?
A. Normal sensation
B. Mild dysarthria
C. Normal visual fields
D. Correct age response
Answer: B. Mild dysarthria
Question 5
Which principle should the examiner follow?
