, NIH STROKE SCALE (NIHSS) GROUP D
CERTIFICATION TEST - PATIENT 1-6
SCORING GUIDE
130 QUESTIONS
TABLE OF CONTENTS
# TOPIC
1 Accurately score all NIHSS items in diverse and complex clinical scenarios
2 Differentiate between similar neurological findings that lead to different scores
3 Apply NIHSS scoring rules to atypical presentations and edge cases
4 Critically evaluate the impact of comorbidities and patient factors on scoring
5 Synthesize NIHSS findings to guide clinical decision-making in acute stroke
6 NIH Stroke Scale
7 NIHSS
8 Group D Certification Test
9 Patient 1
10 6 Scoring Guide
11 Foundations of Neurology / Stroke Assessment
12 Applied Neurology / Stroke Assessment
13 Advanced Neurology / Stroke Assessment
14 Neurology / Stroke Assessment Review
Page 1
,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).
Page 3
CERTIFICATION TEST - PATIENT 1-6
SCORING GUIDE
130 QUESTIONS
TABLE OF CONTENTS
# TOPIC
1 Accurately score all NIHSS items in diverse and complex clinical scenarios
2 Differentiate between similar neurological findings that lead to different scores
3 Apply NIHSS scoring rules to atypical presentations and edge cases
4 Critically evaluate the impact of comorbidities and patient factors on scoring
5 Synthesize NIHSS findings to guide clinical decision-making in acute stroke
6 NIH Stroke Scale
7 NIHSS
8 Group D Certification Test
9 Patient 1
10 6 Scoring Guide
11 Foundations of Neurology / Stroke Assessment
12 Applied Neurology / Stroke Assessment
13 Advanced Neurology / Stroke Assessment
14 Neurology / Stroke Assessment Review
Page 1
,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).
Page 3
