NIHSS Group A Exam Answers 2026 – Patients 1-6 Itemized Scoring Guide & 200 MCQ Practice Test

NIHSS Group A Exam Answers 2026 – Patients 1-6
Itemized Scoring Guide & 200 MCQ Practice Test




Question 1

When assessing Item 1a (Level of Consciousness: Alertness) on the NIHSS, a patient who
responds only with reflex motor outputs or autonomic changes to deep noxious stimuli must
be scored as:

 A) 0 - Alert
 B) 1 - Not alert; somnolent
 C) 2 - Not alert; obtunded

, D) 3 - Reflex movements only or totally unresponsive
Verified Answer: D) 3 - Reflex movements only or totally unresponsive
Explanation: A score of 3 is reserved exclusively for patients who exhibit no purposeful
responses and display only terminal reflex tracking or absolute unresponsiveness during
deep painful stimulation.
Question 2

Under NIHSS guidelines, if a patient has an endotracheal tube, severe arterial language
barriers, or a clearing orofacial trauma that prevents vocalization during Item 1b (LOC
Questions), the examiner should:

 A) Assign a score of 0.
 B) Assign a score of 1.
 C) Assign a score of 2.
 D) Score the item as untestable (UN).
Verified Answer: C) 2
Explanation: The NIHSS does not allow an "untestable" designation for Item 1b. If a
patient cannot speak due to an intubation tube, severe trauma, or profound global aphasia,
they are automatically scored a 2.
Question 3

A patient is asked the current month and their age during Item 1b. They correctly state that
the month is October but miss their age by exactly one calendar year. What is the correct
score?

 A) 0
 B) 1
 C) 2
 D) 3
Verified Answer: B) 1
Explanation: Item 1b awards a 0 for both correct, 1 for one correct, and 2 for zero correct.
Near misses are clinically counted as incorrect to preserve strict inter-rater reliability.
Question 4

When evaluating Item 1c (LOC Commands), the patient is instructed to open/close their eyes
and grip/release their non-paretic hand. The patient cannot physically move their hands due to
severe prior arthritis but attempts to blink intentionally. How should the examiner proceed?

, A) Score 2 because they failed to complete both tasks completely.
 B) Score 0 if another clear, alternative two-step task can be successfully substituted.
 C) Score 1 if they successfully perform an alternate intentional command.
 D) Score 2 and note that the patient has prior arthritis.
Verified Answer: B) Score 0 if another clear, alternative two-step task can be successfully
substituted.
Explanation: If real physical trauma or a distinct structural defect prevents execution of
the hand grip, the examiner may substitute another clear, one-step command. Intentional
effort counts toward fulfillment.
Question 5

During Item 2 (Best Gaze), a patient presents with a severe pre-existing peripheral
oculomotor nerve palsy. How should horizontal extraocular movements be scored?

 A) The examiner should score 0 because it is an old deficit.
 B) The examiner must score the ocular movement as it presents at the moment of evaluation.
 C) The examiner should bypass the score and label it untestable.
 D) The examiner should average the score to a 1.
Verified Answer: B) The examiner must score the ocular movement as it presents at the
moment of evaluation.
Explanation: The NIHSS demands scoring of the actual, real-time neurological status
during evaluation. Prior stroke deficits, injuries, or cranial neuropathies are recorded
directly as deficits.
Question 6

What technique should be utilized during Item 2 (Best Gaze) to confirm whether a gaze palsy
is partial or forced/total?

 A) Applying deep supraorbital pressure.
 B) Performing the oculocephalic (doll's eyes) maneuver.
 C) Utilizing a bright reflex penlight directly into the pupil.
 D) Observing random spontaneous eye movements alone.
Verified Answer: B) Performing the oculocephalic (doll's eyes) maneuver.
Explanation: When a patient cannot follow visual tracking actively, passive head rotation
(oculocephalic maneuver) helps differentiate between a partial and a fixed, forced total
gaze palsy.

, Question 7

When testing Item 3 (Visual Fields), a patient with deep, global aphasia cannot respond
verbally to the examiner's finger-waving. What alternative approach is explicitly permitted?

 A) Skipping the visual field testing entirely.
 B) Scoring the patient as a 3 (bilateral hemianopia).
 C) Utilizing a visual threat maneuver from the periphery toward the eye.
 D) Shining a penlight into the eye and looking for standard pupillary constriction.
Verified Answer: C) Utilizing a visual threat maneuver from the periphery toward the eye.
Explanation: For aphasic or obtunded individuals, testing visual fields is performed using
confrontation via a quick visual threat (blinking or flinching in response to an incoming
hand movement) from all four quadrants.
Question 8

If a patient has a clear, dense left homonymous hemianopia and an asymmetric right
quadrantanopia, what score is assigned to Item 3 (Visual Fields)?

 A) 0
 B) 1
 C) 2
 D) 3
Verified Answer: C) 2
Explanation: Complete homonymous hemianopia yields a score of 2. A score of 3 is
reserved strictly for total blindness or complete bilateral quadrantic/field cuts.
Question 9

During the testing of Item 4 (Facial Palsy), the clinician must encourage the patient to do
which set of movements?

 A) Stick out the tongue and touch the nose with their finger.
 B) Show teeth or smile, close eyes tightly, and lift eyebrows.
 C) Swallow water and cough intensely.
 D) Move the jaw side-to-side and pucker lips.
Verified Answer: B) Show teeth or smile, close eyes tightly, and lift eyebrows.
Explanation: Standard evaluation of cranial nerve VII on the NIHSS relies on observing
symmetry during a smile/grimace, forced eye closure, and forehead wrinkling.