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APEX NIH STROKE SCALE (NIHSS)
CERTIFICATION EXAMINATION STUDY
GUIDE | LATEST UPDATE 2026/2027 |
PRACTICE QUESTIONS AND ANSWERS | AND
DETAILED RATIONALES EXAM REVIEW.
TABLE OF CONTENTS
1. Introduction to the NIH Stroke Scale
2. Level of Consciousness Assessments (Items 1a, 1b, 1c)
3. Ocular Motor Function (Items 2, 3, 4)
4. Visual Field Testing (Item 3)
5. Motor Function Assessment (Items 5, 6)
6. Limb Ataxia Evaluation (Item 7)
7. Sensory Function Testing (Item 8)
8. Language and Aphasia Assessment (Item 9)
9. Dysarthria Evaluation (Item 10)
10. Neglect and Inattention (Item 11)
11. Scoring Interpretation and Clinical Significance
12. Administration Protocols and Best Practices
13. Special Populations and Modifications
14. Documentation and Quality Assurance
15. Integration with Acute Stroke Treatment Algorithms
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Question 1: A 67-year-old patient presents to the emergency department with sudden onset
right-sided weakness and facial droop that began approximately 90 minutes ago. During the
level of consciousness assessment, the patient appears drowsy but responds appropriately
when you call their name loudly and ask them to open their eyes. The patient correctly
answers questions about their age and the current month but requires mild stimulation to
maintain alertness throughout the examination. What is the correct NIHSS score for Item 1a
(Level of Consciousness)?
A) 0 - Alert
B) 1 - Not alert, but arousable by minor stimulation
C) 2 - Not alert, requires repeated stimulation to attend
D) 3 - Unresponsive or obtunded
Correct Answer: 1 - Not alert, but arousable by minor stimulation
The patient demonstrates drowsiness and requires vocal stimulation to respond, which
constitutes "not alert, but arousable by minor stimulation." According to NIHSS criteria, a
score of 1 is assigned when the patient is not fully alert but responds to minor stimulation
such as calling their name or light touch. The patient's ability to answer questions correctly
and maintain attention with mild prompting confirms they are arousable rather than
requiring repeated or painful stimulation.
Question 2: During administration of the NIHSS to a patient with suspected stroke, you ask
the patient to state their age and the current month. The patient correctly states their age but
provides an incorrect month, stating it is "October" when it is actually March. The patient
appears confused about their location and cannot explain why they are in the hospital. What
score should be assigned for Item 1b (LOC Questions)?
A) 0 - Answers both questions correctly
B) 1 - Answers one question correctly
C) 2 - Answers neither question correctly
D) Cannot be determined without additional information
Correct Answer: 1 - Answers one question correctly
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The patient correctly answered one of the two required questions (age) while providing an
incorrect answer for the other (month), which directly corresponds to a score of 1 on Item 1b.
The NIHSS Item 1b specifically requires assessment of orientation to age and month, with
scoring based on the number of correct responses. Aphasic patients who cannot understand
the questions should be scored as 2, but this patient clearly understood and responded,
merely providing one incorrect answer.
Question 3: A stroke patient is being assessed using the NIHSS. When asked to open and
close their eyes and then grip and release their non-paretic hand, the patient successfully
opens and closes their eyes but cannot perform the hand grip task due to severe weakness in
the unaffected hand from a previous injury. How should the examiner score Item 1c (LOC
Commands)?
A) 0 - Performs both tasks correctly
B) 1 - Performs one task correctly
C) 2 - Performs neither task correctly
D) The task should be modified to use a different command
Correct Answer: 1 - Performs one task correctly
The patient successfully performed the eye opening and closing command but could not
complete the hand grip task, resulting in a score of 1 for performing one task correctly. The
NIHSS scoring for Item 1c is based on the patient's ability to perform the two commands,
regardless of why one cannot be completed, unless the inability is due to aphasia or other
communication barrier. In cases of pre-existing limitations, the examiner should attempt
alternative commands but score based on observed performance.
Question 4: During the ocular motor assessment portion of the NIHSS, you ask the patient to
follow your finger horizontally. The patient's eyes move smoothly to the left but show partial
gaze palsy to the right, with the right eye failing to cross the midline completely while the left
eye moves fully. What is the appropriate score for Item 2 (Best Gaze)?
A) 0 - Normal
B) 1 - Partial gaze palsy
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C) 2 - Forced deviation
D) 1 or 2 depending on whether the abnormality can be overcome
Correct Answer: 1 - Partial gaze palsy
Partial gaze palsy is scored when gaze is abnormal in one or both eyes but there is no forced
deviation, which matches this patient's presentation of incomplete rightward movement. A
score of 1 is assigned for partial gaze palsy regardless of whether the deficit can be overcome
by voluntary effort or reflexive activity. Forced deviation, which would warrant a score of 2,
occurs only when the eyes cannot be moved past the midline in any direction.
Question 5: A patient undergoing NIHSS assessment exhibits conjugate deviation of the eyes
to the left side that cannot be overcome by having the patient perform caloric stimulation or
by attempting voluntary gaze in the opposite direction. What score should be assigned for
Item 2 (Best Gaze)?
A) 0 - Normal
B) 1 - Partial gaze palsy
C) 2 - Forced deviation
D) Cannot be scored due to inability to assess
Correct Answer: 2 - Forced deviation
Forced deviation is present when the patient's eyes cannot be moved past the midline in any
direction, even with attempts to overcome the deviation through voluntary effort or reflexive
stimulation. This patient demonstrates complete inability to overcome the leftward conjugate
deviation, which meets the criteria for a score of 2. The key distinction between partial gaze
palsy (score 1) and forced deviation (score 2) is whether any voluntary or reflexive movement
past the midline is possible.
Question 6: During visual field testing as part of the NIHSS, you assess the patient using
confrontation techniques. The patient correctly identifies your fingers in all four quadrants
when tested monocularly. However, when you bring your fingers toward the patient from the
periphery in the upper right quadrant, the patient fails to respond until the fingers reach the
central visual field. What score should be assigned for Item 3 (Visual Fields)?
APEX NIH STROKE SCALE (NIHSS)
CERTIFICATION EXAMINATION STUDY
GUIDE | LATEST UPDATE 2026/2027 |
PRACTICE QUESTIONS AND ANSWERS | AND
DETAILED RATIONALES EXAM REVIEW.
TABLE OF CONTENTS
1. Introduction to the NIH Stroke Scale
2. Level of Consciousness Assessments (Items 1a, 1b, 1c)
3. Ocular Motor Function (Items 2, 3, 4)
4. Visual Field Testing (Item 3)
5. Motor Function Assessment (Items 5, 6)
6. Limb Ataxia Evaluation (Item 7)
7. Sensory Function Testing (Item 8)
8. Language and Aphasia Assessment (Item 9)
9. Dysarthria Evaluation (Item 10)
10. Neglect and Inattention (Item 11)
11. Scoring Interpretation and Clinical Significance
12. Administration Protocols and Best Practices
13. Special Populations and Modifications
14. Documentation and Quality Assurance
15. Integration with Acute Stroke Treatment Algorithms
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Question 1: A 67-year-old patient presents to the emergency department with sudden onset
right-sided weakness and facial droop that began approximately 90 minutes ago. During the
level of consciousness assessment, the patient appears drowsy but responds appropriately
when you call their name loudly and ask them to open their eyes. The patient correctly
answers questions about their age and the current month but requires mild stimulation to
maintain alertness throughout the examination. What is the correct NIHSS score for Item 1a
(Level of Consciousness)?
A) 0 - Alert
B) 1 - Not alert, but arousable by minor stimulation
C) 2 - Not alert, requires repeated stimulation to attend
D) 3 - Unresponsive or obtunded
Correct Answer: 1 - Not alert, but arousable by minor stimulation
The patient demonstrates drowsiness and requires vocal stimulation to respond, which
constitutes "not alert, but arousable by minor stimulation." According to NIHSS criteria, a
score of 1 is assigned when the patient is not fully alert but responds to minor stimulation
such as calling their name or light touch. The patient's ability to answer questions correctly
and maintain attention with mild prompting confirms they are arousable rather than
requiring repeated or painful stimulation.
Question 2: During administration of the NIHSS to a patient with suspected stroke, you ask
the patient to state their age and the current month. The patient correctly states their age but
provides an incorrect month, stating it is "October" when it is actually March. The patient
appears confused about their location and cannot explain why they are in the hospital. What
score should be assigned for Item 1b (LOC Questions)?
A) 0 - Answers both questions correctly
B) 1 - Answers one question correctly
C) 2 - Answers neither question correctly
D) Cannot be determined without additional information
Correct Answer: 1 - Answers one question correctly
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The patient correctly answered one of the two required questions (age) while providing an
incorrect answer for the other (month), which directly corresponds to a score of 1 on Item 1b.
The NIHSS Item 1b specifically requires assessment of orientation to age and month, with
scoring based on the number of correct responses. Aphasic patients who cannot understand
the questions should be scored as 2, but this patient clearly understood and responded,
merely providing one incorrect answer.
Question 3: A stroke patient is being assessed using the NIHSS. When asked to open and
close their eyes and then grip and release their non-paretic hand, the patient successfully
opens and closes their eyes but cannot perform the hand grip task due to severe weakness in
the unaffected hand from a previous injury. How should the examiner score Item 1c (LOC
Commands)?
A) 0 - Performs both tasks correctly
B) 1 - Performs one task correctly
C) 2 - Performs neither task correctly
D) The task should be modified to use a different command
Correct Answer: 1 - Performs one task correctly
The patient successfully performed the eye opening and closing command but could not
complete the hand grip task, resulting in a score of 1 for performing one task correctly. The
NIHSS scoring for Item 1c is based on the patient's ability to perform the two commands,
regardless of why one cannot be completed, unless the inability is due to aphasia or other
communication barrier. In cases of pre-existing limitations, the examiner should attempt
alternative commands but score based on observed performance.
Question 4: During the ocular motor assessment portion of the NIHSS, you ask the patient to
follow your finger horizontally. The patient's eyes move smoothly to the left but show partial
gaze palsy to the right, with the right eye failing to cross the midline completely while the left
eye moves fully. What is the appropriate score for Item 2 (Best Gaze)?
A) 0 - Normal
B) 1 - Partial gaze palsy
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C) 2 - Forced deviation
D) 1 or 2 depending on whether the abnormality can be overcome
Correct Answer: 1 - Partial gaze palsy
Partial gaze palsy is scored when gaze is abnormal in one or both eyes but there is no forced
deviation, which matches this patient's presentation of incomplete rightward movement. A
score of 1 is assigned for partial gaze palsy regardless of whether the deficit can be overcome
by voluntary effort or reflexive activity. Forced deviation, which would warrant a score of 2,
occurs only when the eyes cannot be moved past the midline in any direction.
Question 5: A patient undergoing NIHSS assessment exhibits conjugate deviation of the eyes
to the left side that cannot be overcome by having the patient perform caloric stimulation or
by attempting voluntary gaze in the opposite direction. What score should be assigned for
Item 2 (Best Gaze)?
A) 0 - Normal
B) 1 - Partial gaze palsy
C) 2 - Forced deviation
D) Cannot be scored due to inability to assess
Correct Answer: 2 - Forced deviation
Forced deviation is present when the patient's eyes cannot be moved past the midline in any
direction, even with attempts to overcome the deviation through voluntary effort or reflexive
stimulation. This patient demonstrates complete inability to overcome the leftward conjugate
deviation, which meets the criteria for a score of 2. The key distinction between partial gaze
palsy (score 1) and forced deviation (score 2) is whether any voluntary or reflexive movement
past the midline is possible.
Question 6: During visual field testing as part of the NIHSS, you assess the patient using
confrontation techniques. The patient correctly identifies your fingers in all four quadrants
when tested monocularly. However, when you bring your fingers toward the patient from the
periphery in the upper right quadrant, the patient fails to respond until the fingers reach the
central visual field. What score should be assigned for Item 3 (Visual Fields)?
