APEX NIHSS Group A - Patients 1-6 (Complete) NIH Stroke Scale Certification | 2026/2027 Edition
APEX NIH Stroke Scale Group A Patients 1-6 (Complete)
Verified Answers - 2026/2027 Edition
Comprehensive Certification Examination | 60 Multiple-Choice Questions | Aligned with NIH Stroke Scale
International Standards, AHA/ASA Guidelines, and APEX NIHSS Testing Protocol
Section 1: NIHSS Overview & Administration
Q1: What is the primary purpose of the NIH Stroke Scale (NIHSS) in clinical practice?
A. To definitively diagnose the type of stroke (ischemic vs. hemorrhagic) on clinical grounds alone.
B. To provide a standardized, quantifiable measure of stroke-related neurologic deficit severity for treatment
decisions, prognosis, and serial assessment. *[CORRECT]*
C. To determine the exact anatomic location of the stroke within the brain parenchyma.
D. To replace neuroimaging such as CT and MRI in acute stroke evaluation.
Correct Answer: B
Rationale: The NIHSS is a 15-item standardized neurologic examination yielding a score from 0-42 that quantifies stroke
severity, guides treatment eligibility (e.g., tPA), allows serial comparison, and predicts prognosis. It does NOT diagnose stroke
type or location—CT/MRI are required for that. APEX and AHA/ASA certification standards emphasize that NIHSS is an
assessment tool, not a diagnostic replacement for neuroimaging.
Q2: According to AHA/ASA and APEX NIHSS testing protocol, when should the initial NIHSS be performed on
a patient with suspected acute ischemic stroke?
A. Within 60 minutes of ED arrival, after all laboratory and imaging results are available.
B. As quickly as possible upon patient arrival, before IV access is established, to avoid delay in scoring.
*[CORRECT]*
C. Only after tPA has been administered, to document baseline deficits for outcome comparison.
D. Within 24 hours of admission, after the patient is fully stabilized in the ICU.
Correct Answer: B
Rationale: The NIHSS must be performed immediately upon patient arrival (ideally within 10 minutes) as part of the acute
stroke pathway because it determines tPA eligibility, guides escalation to thrombectomy, and provides the baseline for serial
assessments. Waiting for labs/imaging delays time-critical decision-making. The APEX certification and AHA/ASA guidelines
require a baseline NIHSS before any treatment is initiated.
Q3: Which statement about NIHSS inter-rater reliability is MOST accurate?
A. The NIHSS has poor inter-rater reliability and should only be administered by stroke neurologists.
B. The NIHSS demonstrates excellent inter-rater reliability when administered by trained and certified clinicians
using standardized instructions. *[CORRECT]*
C. Inter-rater reliability is acceptable only in research settings, not in community hospitals.
D. Reliability depends primarily on the patient's level of consciousness rather than examiner training.
Correct Answer: B
Rationale: When administered by certified clinicians using the standardized instructions in the APEX/NINDS training, the
NIHSS achieves high inter-rater reliability (kappa >0.85), even across disciplines (physicians, nurses, paramedics). This is the
rationale for mandatory certification and recertification every 1-2 years per APEX/AHA standards. Reliability is
examiner-driven, not patient-driven.
APEX NIH Stroke Scale - Verified Answers 60 Questions | Recall / Application / Analysis Page 1
,APEX NIHSS Group A - Patients 1-6 (Complete) NIH Stroke Scale Certification | 2026/2027 Edition
Q4: Which NIHSS total score range corresponds to a MODERATE stroke severity classification?
A. 0 (no deficit)
B. 1-4 (minor stroke)
C. 5-15 (moderate stroke) *[CORRECT]*
D. 21-42 (severe stroke)
Correct Answer: C
Rationale: Standard NIHSS severity classifications are: 0 = no stroke, 1-4 = minor stroke, 5-15 = moderate stroke, 16-20 =
moderate-severe stroke, and 21-42 = severe stroke. The APEX certification and AHA/ASA guidelines use these cut points to
correlate with prognosis, tPA benefit, and thrombectomy eligibility. A score of 16 or higher is the traditional threshold for
endovascular therapy consideration in large vessel occlusion.
Q5: Which of the following is the MOST common administration error that compromises NIHSS scoring
accuracy?
A. Testing pinprick sensation before motor function to avoid sensitization.
B. Coaching or cueing the patient beyond the standardized script (e.g., rephrasing questions or repeating
commands more than allowed). *[CORRECT]*
C. Performing the exam in a quiet room with adequate lighting.
D. Recording the worst-ever deficit rather than the deficit at the time of examination.
Correct Answer: B
Rationale: A frequent NIHSS administration error is deviating from the standardized script by rephrasing questions, repeating
commands beyond the allowed number of attempts, or cueing the patient; this inflates or deflates scores and reduces reliability.
Per APEX/NINDS training, examiners must read the exact script and accept the first observable response. The exam must
capture the deficit AT THE TIME OF EXAMINATION, not historical worst deficits.
Section 2: Patient 1 - Full Assessment
PATIENT 1 SCENARIO: A 68-year-old male arrives at the ED 4 hours after symptom onset. He is awake, responds to
questions appropriately but is mildly confused about the date. He answers "June" when asked the current month
(correct) and gives his correct age of 68. He opens both eyes and grips both hands on command. Horizontal gaze is full
in both directions. Visual fields by confrontation are intact bilaterally. On facial examination, the left nasolabial fold is
flattened and the left corner of the mouth droops with smiling. Motor testing: Right arm and leg maintain position for 10
seconds without drift. Left arm drifts down to a 45-degree angle by 5 seconds but does not hit the bed. Left leg drifts to
an intermediate position by 5 seconds. No ataxia is noted on finger-to-nose or heel-to-shin testing. Pinprick testing
reveals mild decreased sensation on the left face, arm, and leg compared to the right. Speech is fluent but has slight
word-finding pauses; he names objects correctly, reads a sentence aloud, and follows 3-step commands. Articulation is
clear. No evidence of neglect on double simultaneous stimulation.
Q6: Patient 1 is awake, responds immediately to verbal greeting, and answers questions appropriately. What is
the correct score for Item 1a (Level of Consciousness)?
A. 0 - Alert; keenly responsive *[CORRECT]*
B. 1 - Not alert, but arousable by minor stimulation
C. 2 - Not alert; requires repeated stimulation
D. 3 - Responds only with reflex motor activity or unresponsive
Correct Answer: A
Rationale: Item 1a scores the patient's baseline responsiveness. A patient who is awake, alert, and responds immediately to
verbal greeting scores 0. Scores of 1, 2, and 3 require progressively more stimulation. The APEX methodology emphasizes that
1a is graded BEFORE any other items; even if the patient is mildly confused about the date (which would affect 1b), 1a reflects
only baseline arousal, not orientation.
APEX NIH Stroke Scale - Verified Answers 60 Questions | Recall / Application / Analysis Page 2
, APEX NIHSS Group A - Patients 1-6 (Complete) NIH Stroke Scale Certification | 2026/2027 Edition
Q7: Patient 1 answers "June" when asked the current month (correct) and states his age as 68 (correct). What is
the correct score for Item 1b (LOC Questions)?
A. 0 - Answers both correctly *[CORRECT]*
B. 1 - Answers one correctly
C. 2 - Answers neither correctly
D. UN - Untestable due to aphasia
Correct Answer: A
Rationale: Item 1b requires asking the patient to state the current month and their age; only the FIRST answer is scored (no
second chances). Patient 1 answered both correctly, scoring 0. A score of 1 requires one correct answer; a score of 2 indicates
both wrong. The APEX protocol notes that aphasic patients who cannot answer at all are scored 2 (not UN, which is reserved
for intubated or comatose patients in 1b/1c).
Q8: Patient 1 opens both eyes AND grips both hands on command. What is the correct score for Item 1c (LOC
Commands)?
A. 0 - Performs both tasks correctly *[CORRECT]*
B. 1 - Performs one task correctly
C. 2 - Performs neither task correctly
D. UN - Untestable due to weakness
Correct Answer: A
Rationale: Item 1c tests the ability to follow two commands: (1) open and close the eyes, and (2) grip and release the
non-paretic hand. Patient 1 performed both tasks, scoring 0. A score of 1 requires one task performed; 2 = neither task. The
APEX standard specifies that if the patient has hemiparesis, the unaffected hand is tested; only the first attempt is scored. Item
1c is not scored UN—the "UN" designation does not apply here.
Q9: Patient 1 demonstrates full horizontal eye movement in both directions with no gaze preference. What is the
correct score for Item 2 (Best Gaze)?
A. 0 - Normal horizontal movement *[CORRECT]*
B. 1 - Partial gaze palsy
C. 2 - Forced deviation or total gaze paresis
D. UN - Untestable
Correct Answer: A
Rationale: Item 2 tests ONLY horizontal eye movement (not vertical). Patient 1 has full horizontal gaze in both directions,
scoring 0. A score of 1 indicates partial gaze palsy (eyes can move past midline but not fully); 2 = forced deviation that cannot
be overcome by voluntary gaze or oculocephalic maneuver. The APEX standard notes that vertical gaze abnormalities and
isolated cranial nerve III/IV/VI palsies are NOT scored in Item 2.
Q10: Patient 1 has intact visual fields by confrontation in all four quadrants bilaterally. What is the correct score
for Item 3 (Visual Fields)?
A. 0 - No visual loss *[CORRECT]*
B. 1 - Partial hemianopia or quadrantanopia
C. 2 - Complete hemianopia
D. 3 - Bilateral hemianopia including blindness
Correct Answer: A
Rationale: Item 3 uses confrontation testing or visual threat to detect field cuts. Patient 1 has intact fields in all four quadrants
bilaterally, scoring 0. A score of 1 indicates partial hemianopia or quadrantanopia; 2 = complete hemianopia; 3 = bilateral
hemianopia or cortical blindness. The APEX methodology notes that patients with decreased consciousness can be assessed by
visual threat (blink to threat) in each quadrant.
APEX NIH Stroke Scale - Verified Answers 60 Questions | Recall / Application / Analysis Page 3
APEX NIH Stroke Scale Group A Patients 1-6 (Complete)
Verified Answers - 2026/2027 Edition
Comprehensive Certification Examination | 60 Multiple-Choice Questions | Aligned with NIH Stroke Scale
International Standards, AHA/ASA Guidelines, and APEX NIHSS Testing Protocol
Section 1: NIHSS Overview & Administration
Q1: What is the primary purpose of the NIH Stroke Scale (NIHSS) in clinical practice?
A. To definitively diagnose the type of stroke (ischemic vs. hemorrhagic) on clinical grounds alone.
B. To provide a standardized, quantifiable measure of stroke-related neurologic deficit severity for treatment
decisions, prognosis, and serial assessment. *[CORRECT]*
C. To determine the exact anatomic location of the stroke within the brain parenchyma.
D. To replace neuroimaging such as CT and MRI in acute stroke evaluation.
Correct Answer: B
Rationale: The NIHSS is a 15-item standardized neurologic examination yielding a score from 0-42 that quantifies stroke
severity, guides treatment eligibility (e.g., tPA), allows serial comparison, and predicts prognosis. It does NOT diagnose stroke
type or location—CT/MRI are required for that. APEX and AHA/ASA certification standards emphasize that NIHSS is an
assessment tool, not a diagnostic replacement for neuroimaging.
Q2: According to AHA/ASA and APEX NIHSS testing protocol, when should the initial NIHSS be performed on
a patient with suspected acute ischemic stroke?
A. Within 60 minutes of ED arrival, after all laboratory and imaging results are available.
B. As quickly as possible upon patient arrival, before IV access is established, to avoid delay in scoring.
*[CORRECT]*
C. Only after tPA has been administered, to document baseline deficits for outcome comparison.
D. Within 24 hours of admission, after the patient is fully stabilized in the ICU.
Correct Answer: B
Rationale: The NIHSS must be performed immediately upon patient arrival (ideally within 10 minutes) as part of the acute
stroke pathway because it determines tPA eligibility, guides escalation to thrombectomy, and provides the baseline for serial
assessments. Waiting for labs/imaging delays time-critical decision-making. The APEX certification and AHA/ASA guidelines
require a baseline NIHSS before any treatment is initiated.
Q3: Which statement about NIHSS inter-rater reliability is MOST accurate?
A. The NIHSS has poor inter-rater reliability and should only be administered by stroke neurologists.
B. The NIHSS demonstrates excellent inter-rater reliability when administered by trained and certified clinicians
using standardized instructions. *[CORRECT]*
C. Inter-rater reliability is acceptable only in research settings, not in community hospitals.
D. Reliability depends primarily on the patient's level of consciousness rather than examiner training.
Correct Answer: B
Rationale: When administered by certified clinicians using the standardized instructions in the APEX/NINDS training, the
NIHSS achieves high inter-rater reliability (kappa >0.85), even across disciplines (physicians, nurses, paramedics). This is the
rationale for mandatory certification and recertification every 1-2 years per APEX/AHA standards. Reliability is
examiner-driven, not patient-driven.
APEX NIH Stroke Scale - Verified Answers 60 Questions | Recall / Application / Analysis Page 1
,APEX NIHSS Group A - Patients 1-6 (Complete) NIH Stroke Scale Certification | 2026/2027 Edition
Q4: Which NIHSS total score range corresponds to a MODERATE stroke severity classification?
A. 0 (no deficit)
B. 1-4 (minor stroke)
C. 5-15 (moderate stroke) *[CORRECT]*
D. 21-42 (severe stroke)
Correct Answer: C
Rationale: Standard NIHSS severity classifications are: 0 = no stroke, 1-4 = minor stroke, 5-15 = moderate stroke, 16-20 =
moderate-severe stroke, and 21-42 = severe stroke. The APEX certification and AHA/ASA guidelines use these cut points to
correlate with prognosis, tPA benefit, and thrombectomy eligibility. A score of 16 or higher is the traditional threshold for
endovascular therapy consideration in large vessel occlusion.
Q5: Which of the following is the MOST common administration error that compromises NIHSS scoring
accuracy?
A. Testing pinprick sensation before motor function to avoid sensitization.
B. Coaching or cueing the patient beyond the standardized script (e.g., rephrasing questions or repeating
commands more than allowed). *[CORRECT]*
C. Performing the exam in a quiet room with adequate lighting.
D. Recording the worst-ever deficit rather than the deficit at the time of examination.
Correct Answer: B
Rationale: A frequent NIHSS administration error is deviating from the standardized script by rephrasing questions, repeating
commands beyond the allowed number of attempts, or cueing the patient; this inflates or deflates scores and reduces reliability.
Per APEX/NINDS training, examiners must read the exact script and accept the first observable response. The exam must
capture the deficit AT THE TIME OF EXAMINATION, not historical worst deficits.
Section 2: Patient 1 - Full Assessment
PATIENT 1 SCENARIO: A 68-year-old male arrives at the ED 4 hours after symptom onset. He is awake, responds to
questions appropriately but is mildly confused about the date. He answers "June" when asked the current month
(correct) and gives his correct age of 68. He opens both eyes and grips both hands on command. Horizontal gaze is full
in both directions. Visual fields by confrontation are intact bilaterally. On facial examination, the left nasolabial fold is
flattened and the left corner of the mouth droops with smiling. Motor testing: Right arm and leg maintain position for 10
seconds without drift. Left arm drifts down to a 45-degree angle by 5 seconds but does not hit the bed. Left leg drifts to
an intermediate position by 5 seconds. No ataxia is noted on finger-to-nose or heel-to-shin testing. Pinprick testing
reveals mild decreased sensation on the left face, arm, and leg compared to the right. Speech is fluent but has slight
word-finding pauses; he names objects correctly, reads a sentence aloud, and follows 3-step commands. Articulation is
clear. No evidence of neglect on double simultaneous stimulation.
Q6: Patient 1 is awake, responds immediately to verbal greeting, and answers questions appropriately. What is
the correct score for Item 1a (Level of Consciousness)?
A. 0 - Alert; keenly responsive *[CORRECT]*
B. 1 - Not alert, but arousable by minor stimulation
C. 2 - Not alert; requires repeated stimulation
D. 3 - Responds only with reflex motor activity or unresponsive
Correct Answer: A
Rationale: Item 1a scores the patient's baseline responsiveness. A patient who is awake, alert, and responds immediately to
verbal greeting scores 0. Scores of 1, 2, and 3 require progressively more stimulation. The APEX methodology emphasizes that
1a is graded BEFORE any other items; even if the patient is mildly confused about the date (which would affect 1b), 1a reflects
only baseline arousal, not orientation.
APEX NIH Stroke Scale - Verified Answers 60 Questions | Recall / Application / Analysis Page 2
, APEX NIHSS Group A - Patients 1-6 (Complete) NIH Stroke Scale Certification | 2026/2027 Edition
Q7: Patient 1 answers "June" when asked the current month (correct) and states his age as 68 (correct). What is
the correct score for Item 1b (LOC Questions)?
A. 0 - Answers both correctly *[CORRECT]*
B. 1 - Answers one correctly
C. 2 - Answers neither correctly
D. UN - Untestable due to aphasia
Correct Answer: A
Rationale: Item 1b requires asking the patient to state the current month and their age; only the FIRST answer is scored (no
second chances). Patient 1 answered both correctly, scoring 0. A score of 1 requires one correct answer; a score of 2 indicates
both wrong. The APEX protocol notes that aphasic patients who cannot answer at all are scored 2 (not UN, which is reserved
for intubated or comatose patients in 1b/1c).
Q8: Patient 1 opens both eyes AND grips both hands on command. What is the correct score for Item 1c (LOC
Commands)?
A. 0 - Performs both tasks correctly *[CORRECT]*
B. 1 - Performs one task correctly
C. 2 - Performs neither task correctly
D. UN - Untestable due to weakness
Correct Answer: A
Rationale: Item 1c tests the ability to follow two commands: (1) open and close the eyes, and (2) grip and release the
non-paretic hand. Patient 1 performed both tasks, scoring 0. A score of 1 requires one task performed; 2 = neither task. The
APEX standard specifies that if the patient has hemiparesis, the unaffected hand is tested; only the first attempt is scored. Item
1c is not scored UN—the "UN" designation does not apply here.
Q9: Patient 1 demonstrates full horizontal eye movement in both directions with no gaze preference. What is the
correct score for Item 2 (Best Gaze)?
A. 0 - Normal horizontal movement *[CORRECT]*
B. 1 - Partial gaze palsy
C. 2 - Forced deviation or total gaze paresis
D. UN - Untestable
Correct Answer: A
Rationale: Item 2 tests ONLY horizontal eye movement (not vertical). Patient 1 has full horizontal gaze in both directions,
scoring 0. A score of 1 indicates partial gaze palsy (eyes can move past midline but not fully); 2 = forced deviation that cannot
be overcome by voluntary gaze or oculocephalic maneuver. The APEX standard notes that vertical gaze abnormalities and
isolated cranial nerve III/IV/VI palsies are NOT scored in Item 2.
Q10: Patient 1 has intact visual fields by confrontation in all four quadrants bilaterally. What is the correct score
for Item 3 (Visual Fields)?
A. 0 - No visual loss *[CORRECT]*
B. 1 - Partial hemianopia or quadrantanopia
C. 2 - Complete hemianopia
D. 3 - Bilateral hemianopia including blindness
Correct Answer: A
Rationale: Item 3 uses confrontation testing or visual threat to detect field cuts. Patient 1 has intact fields in all four quadrants
bilaterally, scoring 0. A score of 1 indicates partial hemianopia or quadrantanopia; 2 = complete hemianopia; 3 = bilateral
hemianopia or cortical blindness. The APEX methodology notes that patients with decreased consciousness can be assessed by
visual threat (blink to threat) in each quadrant.
APEX NIH Stroke Scale - Verified Answers 60 Questions | Recall / Application / Analysis Page 3
