,Q1 ACCURATELY SCORE ALL NIHSS ITEMS IN DIVERSE AND COMPLEX CLINICAL
SCENARIOS
A patient with a left hemispheric stroke is asked to perform a motor task. The
patient uses the right hand to gesture but does not follow the verbal command.
Which NIHSS item and score are most appropriate if the patient is alert and has no
aphasia or neglect?
A. Item 1a (LOC) score 1
B. Item 1c (Commands) score 1 CORRECT
C. Item 2 (Gaze) score 1
D. Item 5 (Motor Arm) score 1
RATIONALE: The patient's failure to follow the command despite being alert and without aphasia
indicates an issue with command comprehension or execution, which is scored under 1c. A score
of 1 is given for partial performance (e.g., performs one command). Other items do not directly
assess command following.
Q2 ACCURATELY SCORE ALL NIHSS ITEMS IN DIVERSE AND COMPLEX CLINICAL
SCENARIOS
In a patient with a dense left gaze preference, the examiner uses a mirror to test
conjugate gaze. Which NIHSS scoring principle applies?
A. Mirror testing is not allowed; score based on primary gaze only.
B. Mirror testing is allowed and can overcome gaze deviation, but the item is scored 2 if
deviation is overcome. CORRECT
C. Mirror testing is allowed only if the patient is aphasic.
D. Mirror testing is used to test visual fields, not gaze.
RATIONALE: The NIHSS allows oculocephalic maneuvers or mirror testing to assess gaze. If
gaze deviation can be overcome by such maneuvers, it is scored as 1 (partial gaze palsy); if not
overcome, score 2. Thus, mirror testing can be used and affects the score.
Page 2
,Q3 ACCURATELY SCORE ALL NIHSS ITEMS IN DIVERSE AND COMPLEX CLINICAL
SCENARIOS
A patient with severe aphasia and left hemiparesis is unable to complete visual
field testing. The examiner uses a threat stimulus from the left side. The patient
blinks to threat on the right but not the left. Which visual field score is
appropriate?
A. 0 (no visual loss) because blink to threat is not a valid test
B. 1 (partial hemianopia) because there is asymmetry
C. 2 (complete hemianopia) because the patient does not respond to left threat CORRECT
D. Cannot score due to aphasia; record as untestable.
RATIONALE: The NIHSS allows visual threat testing in patients who cannot cooperate with
formal perimetry. A blink to threat on one side but not the other indicates a complete hemianopia,
scored as 2. Aphasia does not preclude scoring; the threat test is valid.
Q4 ACCURATELY SCORE ALL NIHSS ITEMS IN DIVERSE AND COMPLEX CLINICAL
SCENARIOS
A patient with a right hemispheric stroke has left-sided neglect. When asked to
identify the number of fingers shown by the examiner, the patient reports seeing
only 3 fingers on the right side. Which NIHSS item and score is most accurate?
A. Item 3 (Visual Fields) score 1 because of extinction on double simultaneous stimulation
B. Item 11 (Extinction and Inattention) score 1 because of visual neglect CORRECT
C. Item 9 (Language) score 1 because of impaired naming
D. Item 10 (Dysarthria) score 1 because of slurred speech
RATIONALE: The patient's failure to attend to the left visual field when both sides are stimulated
simultaneously is classic extinction, scored under Item 11. Even though visual fields may be
intact, extinction is a neglect phenomenon, not a visual field defect. Thus, score 1 (extinction to
visual stimulation).
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, Q5 ACCURATELY SCORE ALL NIHSS ITEMS IN DIVERSE AND COMPLEX CLINICAL
SCENARIOS
A patient with a brainstem stroke has difficulty with articulation but no aphasia.
On examination, the patient's speech is slurred, but the examiner can understand
most words. The patient also has mild facial weakness. What is the appropriate
NIHSS score for dysarthria?
A. 0 (normal)
B. 1 (mild to moderate dysarthria) CORRECT
C. 2 (severe dysarthria, unintelligible)
D. 9 (untestable due to intubation)
RATIONALE: The patient's slurred speech that is mostly understandable is consistent with
mild-to-moderate dysarthria, scored as 1. Severe dysarthria (score 2) would be if speech is
unintelligible or the patient cannot produce speech. Facial weakness does not automatically
upgrade to 2.
Q6 ACCURATELY SCORE ALL NIHSS ITEMS IN DIVERSE AND COMPLEX CLINICAL
SCENARIOS
In a patient with aphasia, the examiner attempts to test best language by asking
the patient to describe a picture. The patient produces only a few single words and
cannot form sentences. Which NIHSS language score is most appropriate?
A. 0 (no aphasia) because the patient can speak
B. 1 (mild aphasia) because some words are produced
C. 2 (severe aphasia) because speech is limited to single words CORRECT
D. 3 (mute or global aphasia) because no sentences are formed
RATIONALE: The NIHSS language item (Item 9) is scored from 0 to 3. A score of 2 is given for
severe aphasia where the patient has fragmented expression, such as single words, and needs
inference. A score of 3 is for mute or global aphasia with no usable speech. Thus, single-word
production is score 2.
Page 4
SCENARIOS
A patient with a left hemispheric stroke is asked to perform a motor task. The
patient uses the right hand to gesture but does not follow the verbal command.
Which NIHSS item and score are most appropriate if the patient is alert and has no
aphasia or neglect?
A. Item 1a (LOC) score 1
B. Item 1c (Commands) score 1 CORRECT
C. Item 2 (Gaze) score 1
D. Item 5 (Motor Arm) score 1
RATIONALE: The patient's failure to follow the command despite being alert and without aphasia
indicates an issue with command comprehension or execution, which is scored under 1c. A score
of 1 is given for partial performance (e.g., performs one command). Other items do not directly
assess command following.
Q2 ACCURATELY SCORE ALL NIHSS ITEMS IN DIVERSE AND COMPLEX CLINICAL
SCENARIOS
In a patient with a dense left gaze preference, the examiner uses a mirror to test
conjugate gaze. Which NIHSS scoring principle applies?
A. Mirror testing is not allowed; score based on primary gaze only.
B. Mirror testing is allowed and can overcome gaze deviation, but the item is scored 2 if
deviation is overcome. CORRECT
C. Mirror testing is allowed only if the patient is aphasic.
D. Mirror testing is used to test visual fields, not gaze.
RATIONALE: The NIHSS allows oculocephalic maneuvers or mirror testing to assess gaze. If
gaze deviation can be overcome by such maneuvers, it is scored as 1 (partial gaze palsy); if not
overcome, score 2. Thus, mirror testing can be used and affects the score.
Page 2
,Q3 ACCURATELY SCORE ALL NIHSS ITEMS IN DIVERSE AND COMPLEX CLINICAL
SCENARIOS
A patient with severe aphasia and left hemiparesis is unable to complete visual
field testing. The examiner uses a threat stimulus from the left side. The patient
blinks to threat on the right but not the left. Which visual field score is
appropriate?
A. 0 (no visual loss) because blink to threat is not a valid test
B. 1 (partial hemianopia) because there is asymmetry
C. 2 (complete hemianopia) because the patient does not respond to left threat CORRECT
D. Cannot score due to aphasia; record as untestable.
RATIONALE: The NIHSS allows visual threat testing in patients who cannot cooperate with
formal perimetry. A blink to threat on one side but not the other indicates a complete hemianopia,
scored as 2. Aphasia does not preclude scoring; the threat test is valid.
Q4 ACCURATELY SCORE ALL NIHSS ITEMS IN DIVERSE AND COMPLEX CLINICAL
SCENARIOS
A patient with a right hemispheric stroke has left-sided neglect. When asked to
identify the number of fingers shown by the examiner, the patient reports seeing
only 3 fingers on the right side. Which NIHSS item and score is most accurate?
A. Item 3 (Visual Fields) score 1 because of extinction on double simultaneous stimulation
B. Item 11 (Extinction and Inattention) score 1 because of visual neglect CORRECT
C. Item 9 (Language) score 1 because of impaired naming
D. Item 10 (Dysarthria) score 1 because of slurred speech
RATIONALE: The patient's failure to attend to the left visual field when both sides are stimulated
simultaneously is classic extinction, scored under Item 11. Even though visual fields may be
intact, extinction is a neglect phenomenon, not a visual field defect. Thus, score 1 (extinction to
visual stimulation).
Page 3
, Q5 ACCURATELY SCORE ALL NIHSS ITEMS IN DIVERSE AND COMPLEX CLINICAL
SCENARIOS
A patient with a brainstem stroke has difficulty with articulation but no aphasia.
On examination, the patient's speech is slurred, but the examiner can understand
most words. The patient also has mild facial weakness. What is the appropriate
NIHSS score for dysarthria?
A. 0 (normal)
B. 1 (mild to moderate dysarthria) CORRECT
C. 2 (severe dysarthria, unintelligible)
D. 9 (untestable due to intubation)
RATIONALE: The patient's slurred speech that is mostly understandable is consistent with
mild-to-moderate dysarthria, scored as 1. Severe dysarthria (score 2) would be if speech is
unintelligible or the patient cannot produce speech. Facial weakness does not automatically
upgrade to 2.
Q6 ACCURATELY SCORE ALL NIHSS ITEMS IN DIVERSE AND COMPLEX CLINICAL
SCENARIOS
In a patient with aphasia, the examiner attempts to test best language by asking
the patient to describe a picture. The patient produces only a few single words and
cannot form sentences. Which NIHSS language score is most appropriate?
A. 0 (no aphasia) because the patient can speak
B. 1 (mild aphasia) because some words are produced
C. 2 (severe aphasia) because speech is limited to single words CORRECT
D. 3 (mute or global aphasia) because no sentences are formed
RATIONALE: The NIHSS language item (Item 9) is scored from 0 to 3. A score of 2 is given for
severe aphasia where the patient has fragmented expression, such as single words, and needs
inference. A score of 3 is for mute or global aphasia with no usable speech. Thus, single-word
production is score 2.
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