, NIH STROKE SCALE (NIHSS) GROUP E
CERTIFICATION - QUESTION PRACTICE
EXAM.
120 QUESTIONS
TABLE OF CONTENTS
# TOPIC
1 Accurately score all NIHSS items in complex clinical scenarios
2 Distinguish between subtle scoring differences that impact treatment decisions
3 Apply NIHSS principles to novel and atypical presentations
4 Critically evaluate inter-rater reliability and sources of scoring error
5 NIH Stroke Scale
6 NIHSS
7 Group E Certification
8 Question Practice Exam.
9 Foundations of Neurology / Stroke Assessment
10 Applied Neurology / Stroke Assessment
11 Advanced Neurology / Stroke Assessment
12 Neurology / Stroke Assessment Review
Page 1
,Q1 ACCURATELY SCORE ALL NIHSS ITEMS IN COMPLEX CLINICAL SCENARIOS
A patient with acute stroke is unable to follow any commands, but when a noxious
stimulus is applied to the left arm, the patient withdraws the right arm. What is the
correct score for Item 1c (Commands)?
A. 0 - Performs both tasks correctly
B. 1 - Performs one task correctly
C. 2 - Performs neither task correctly CORRECT
D. Not testable due to aphasia
RATIONALE: Item 1c requires the patient to perform two commands (open/close eyes,
grip/release hand). The patient cannot follow any commands, so score 2. The withdrawal is a
reflex/withdrawal to pain, not a purposeful command following. Even with aphasia, commands
are attempted; the inability to perform either task yields a score of 2.
Q2 ACCURATELY SCORE ALL NIHSS ITEMS IN COMPLEX CLINICAL SCENARIOS
In scoring Item 5 (Motor Arm), a patient holds the left arm at 90° for 8 seconds
before it drifts down to the bed. The right arm holds for 10 seconds without drift.
What are the correct scores for the left and right arms, respectively?
A. Left 1, Right 0 CORRECT
B. Left 2, Right 0
C. Left 1, Right 1
D. Left 2, Right 1
RATIONALE: For Item 5, the arm must be held for 10 seconds. The left arm drifts before 10
seconds but does not hit the bed until after 8 seconds, so it scores 1 (drift). The right arm holds
fully, score 0. A score of 2 is for drift that hits the bed within 10 seconds, which does not occur
here.
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, Q3 ACCURATELY SCORE ALL NIHSS ITEMS IN COMPLEX CLINICAL SCENARIOS
A patient with left hemineglect is asked to draw a clock. They draw all numbers on
the right side of the clock face. According to NIHSS Item 11 (Extinction and
Inattention), what score is most appropriate?
A. 0 - No neglect
B. 1 - Hemi-inattention in one modality CORRECT
C. 2 - Hemi-inattention in more than one modality
D. 1 - Visual field cut only
RATIONALE: Item 11 scores 1 if the patient demonstrates hemi-inattention in one sensory
modality (visual, tactile, auditory, or spatial). Drawing a clock with numbers only on one side
indicates visual-spatial neglect, which is a single modality. A score of 2 requires involvement of
more than one modality, and a visual field cut alone would be scored under Item 3, not Item 11.
Q4 ACCURATELY SCORE ALL NIHSS ITEMS IN COMPLEX CLINICAL SCENARIOS
Which scenario best illustrates the principle that NIHSS items should be scored
based on what the patient actually does, not what the examiner believes they can
do?
A. A patient with severe aphasia is unable to follow commands, but the examiner scores 0
because the patient seems to understand.
B. A patient with a dense hemiplegia refuses to attempt the motor arm item, so the examiner
scores 4 (no movement).
C. A patient with a visual field cut correctly identifies 3 of 4 quadrants, and the examiner scores 1
based on the one missed quadrant. CORRECT
D. A patient with a mild drift that is corrected by the patient is scored 0 because the drift was
momentary.
RATIONALE: The NIHSS instructs to score what is observed, not what the examiner thinks the
patient can do. In option C, the patient actually missed one quadrant, so scoring 1 is correct
based on observation. Option A is incorrect because the score must reflect the inability to follow
commands (score 2). Option B is incorrect because if the patient refuses, the item is not testable
and should be scored as the worst possible (4) only if no effort is made, but the examiner must
attempt to elicit movement. Option D is incorrect because a drift that is corrected still counts as
drift (score 1) if it occurs before 10 seconds.
Page 3
CERTIFICATION - QUESTION PRACTICE
EXAM.
120 QUESTIONS
TABLE OF CONTENTS
# TOPIC
1 Accurately score all NIHSS items in complex clinical scenarios
2 Distinguish between subtle scoring differences that impact treatment decisions
3 Apply NIHSS principles to novel and atypical presentations
4 Critically evaluate inter-rater reliability and sources of scoring error
5 NIH Stroke Scale
6 NIHSS
7 Group E Certification
8 Question Practice Exam.
9 Foundations of Neurology / Stroke Assessment
10 Applied Neurology / Stroke Assessment
11 Advanced Neurology / Stroke Assessment
12 Neurology / Stroke Assessment Review
Page 1
,Q1 ACCURATELY SCORE ALL NIHSS ITEMS IN COMPLEX CLINICAL SCENARIOS
A patient with acute stroke is unable to follow any commands, but when a noxious
stimulus is applied to the left arm, the patient withdraws the right arm. What is the
correct score for Item 1c (Commands)?
A. 0 - Performs both tasks correctly
B. 1 - Performs one task correctly
C. 2 - Performs neither task correctly CORRECT
D. Not testable due to aphasia
RATIONALE: Item 1c requires the patient to perform two commands (open/close eyes,
grip/release hand). The patient cannot follow any commands, so score 2. The withdrawal is a
reflex/withdrawal to pain, not a purposeful command following. Even with aphasia, commands
are attempted; the inability to perform either task yields a score of 2.
Q2 ACCURATELY SCORE ALL NIHSS ITEMS IN COMPLEX CLINICAL SCENARIOS
In scoring Item 5 (Motor Arm), a patient holds the left arm at 90° for 8 seconds
before it drifts down to the bed. The right arm holds for 10 seconds without drift.
What are the correct scores for the left and right arms, respectively?
A. Left 1, Right 0 CORRECT
B. Left 2, Right 0
C. Left 1, Right 1
D. Left 2, Right 1
RATIONALE: For Item 5, the arm must be held for 10 seconds. The left arm drifts before 10
seconds but does not hit the bed until after 8 seconds, so it scores 1 (drift). The right arm holds
fully, score 0. A score of 2 is for drift that hits the bed within 10 seconds, which does not occur
here.
Page 2
, Q3 ACCURATELY SCORE ALL NIHSS ITEMS IN COMPLEX CLINICAL SCENARIOS
A patient with left hemineglect is asked to draw a clock. They draw all numbers on
the right side of the clock face. According to NIHSS Item 11 (Extinction and
Inattention), what score is most appropriate?
A. 0 - No neglect
B. 1 - Hemi-inattention in one modality CORRECT
C. 2 - Hemi-inattention in more than one modality
D. 1 - Visual field cut only
RATIONALE: Item 11 scores 1 if the patient demonstrates hemi-inattention in one sensory
modality (visual, tactile, auditory, or spatial). Drawing a clock with numbers only on one side
indicates visual-spatial neglect, which is a single modality. A score of 2 requires involvement of
more than one modality, and a visual field cut alone would be scored under Item 3, not Item 11.
Q4 ACCURATELY SCORE ALL NIHSS ITEMS IN COMPLEX CLINICAL SCENARIOS
Which scenario best illustrates the principle that NIHSS items should be scored
based on what the patient actually does, not what the examiner believes they can
do?
A. A patient with severe aphasia is unable to follow commands, but the examiner scores 0
because the patient seems to understand.
B. A patient with a dense hemiplegia refuses to attempt the motor arm item, so the examiner
scores 4 (no movement).
C. A patient with a visual field cut correctly identifies 3 of 4 quadrants, and the examiner scores 1
based on the one missed quadrant. CORRECT
D. A patient with a mild drift that is corrected by the patient is scored 0 because the drift was
momentary.
RATIONALE: The NIHSS instructs to score what is observed, not what the examiner thinks the
patient can do. In option C, the patient actually missed one quadrant, so scoring 1 is correct
based on observation. Option A is incorrect because the score must reflect the inability to follow
commands (score 2). Option B is incorrect because if the patient refuses, the item is not testable
and should be scored as the worst possible (4) only if no effort is made, but the examiner must
attempt to elicit movement. Option D is incorrect because a drift that is corrected still counts as
drift (score 1) if it occurs before 10 seconds.
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