Page 1 of 275
NIH STROKE SCALE (NIHSS) GROUP A
CERTIFICATION EXAMINATION
Patient 1–6 Scoring Guide & Comprehensive Question Bank
Table of Contents
SECTION 1: Level of Consciousness — Items 1a, 1b, 1c (Questions 1–35)
SECTION 2: Best Gaze — Item 2 (Questions 36–55)
SECTION 3: Visual Fields — Item 3 (Questions 56–75)
SECTION 4: Facial Palsy — Item 4 (Questions 76–90)
SECTION 5: Motor Arm — Item 5a, 5b (Questions 91–115)
SECTION 6: Motor Leg — Item 6a, 6b (Questions 116–140)
SECTION 7: Limb Ataxia — Item 7 (Questions 141–155)
SECTION 8: Sensory — Item 8 (Questions 156–170)
SECTION 9: Best Language — Item 9 (Questions 171–185)
SECTION 10: Dysarthria — Item 10 (Questions 186–195)
SECTION 11: Extinction/Inattention — Item 11 (Questions 196–205)
SECTION 12: Integrated Patient Scenarios — Group A, Patients 1–6 (Questions 206–210)
SECTION 1: Level of Consciousness — Items 1a, 1b, 1c
**Learning Objectives for SECTION 1:**
- Apply the 0–3 scoring criteria for Item 1a (LOC) based on patient arousability and
responsiveness.
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- Score Item 1b (LOC Questions) correctly based on orientation to month and age.
- Score Item 1c (LOC Commands) correctly based on the patient's ability to open/close eyes and
grip/release hands.
- Differentiate failure due to aphasia from failure due to weakness when scoring Item 1c.
- Apply special rules for intubated, language-barrier, and aphasic patients.
Question 1
Topic: Item 1a — Level of Consciousness
Learning Objective: Apply the 0–3 scoring criteria for LOC based on patient arousability.
Difficulty: Easy
**Question:** A patient is fully alert and keenly responsive upon examination. What is the
correct NIHSS score for Item 1a (Level of Consciousness)?
A. 0
B. 1
C. 2
D. 3
Correct answer: A. 0
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Detailed rationale: A score of 0 for Item 1a is assigned when the patient is alert and keenly
responsive. This represents the normal finding in a patient without impaired consciousness. The
NIHSS scoring definition explicitly states that 0 = Alert, keenly responsive.
Why the other options are incorrect:
- A: Correct. This is the score for a fully alert patient.
- B: A score of 1 indicates the patient is not alert but can be aroused by minor stimulation to
obey, answer, or respond.
- C: A score of 2 indicates the patient is not alert and requires repeated stimulation to attend, or
is obtunded.
- D: A score of 3 indicates the patient responds only with reflex motor or autonomic effects or is
totally unresponsive.
Exam tip: Remember the LOC scoring ladder: 0 = Alert; 1 = Arousable with minor stimulation; 2
= Requires repeated/painful stimulation; 3 = Reflex only/unresponsive.
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**Question 2**
**Topic:** Item 1a — Level of Consciousness
**Learning Objective:** Identify the LOC score for a patient who opens eyes only after painful
stimulation.
**Difficulty:** Easy
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**Question:** A patient opens their eyes only after a painful stimulus is applied. The patient
does not follow commands or answer Questions. What LOC score should be assigned?
A. 0
B. 1
C. 2
D. 3
**Correct answer:** C. 2
**Detailed rationale:** A score of 2 is appropriate when the patient is not alert and requires
repeated stimulation to attend or requires strong or painful stimulation to make movements.
Since the patient requires painful stimulation to open the eyes, a score of 2 is correct.
**Why the other options are incorrect:**
- A: Score 0 requires full alertness.
- B: Score 1 requires arousal with minor stimulation, not painful stimulation.
- D: Score 3 indicates no response other than reflex effects.
**Exam tip:** Painful stimulation → Score 2 (unless no response at all → Score 3).
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**Question 3**
NIH STROKE SCALE (NIHSS) GROUP A
CERTIFICATION EXAMINATION
Patient 1–6 Scoring Guide & Comprehensive Question Bank
Table of Contents
SECTION 1: Level of Consciousness — Items 1a, 1b, 1c (Questions 1–35)
SECTION 2: Best Gaze — Item 2 (Questions 36–55)
SECTION 3: Visual Fields — Item 3 (Questions 56–75)
SECTION 4: Facial Palsy — Item 4 (Questions 76–90)
SECTION 5: Motor Arm — Item 5a, 5b (Questions 91–115)
SECTION 6: Motor Leg — Item 6a, 6b (Questions 116–140)
SECTION 7: Limb Ataxia — Item 7 (Questions 141–155)
SECTION 8: Sensory — Item 8 (Questions 156–170)
SECTION 9: Best Language — Item 9 (Questions 171–185)
SECTION 10: Dysarthria — Item 10 (Questions 186–195)
SECTION 11: Extinction/Inattention — Item 11 (Questions 196–205)
SECTION 12: Integrated Patient Scenarios — Group A, Patients 1–6 (Questions 206–210)
SECTION 1: Level of Consciousness — Items 1a, 1b, 1c
**Learning Objectives for SECTION 1:**
- Apply the 0–3 scoring criteria for Item 1a (LOC) based on patient arousability and
responsiveness.
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- Score Item 1b (LOC Questions) correctly based on orientation to month and age.
- Score Item 1c (LOC Commands) correctly based on the patient's ability to open/close eyes and
grip/release hands.
- Differentiate failure due to aphasia from failure due to weakness when scoring Item 1c.
- Apply special rules for intubated, language-barrier, and aphasic patients.
Question 1
Topic: Item 1a — Level of Consciousness
Learning Objective: Apply the 0–3 scoring criteria for LOC based on patient arousability.
Difficulty: Easy
**Question:** A patient is fully alert and keenly responsive upon examination. What is the
correct NIHSS score for Item 1a (Level of Consciousness)?
A. 0
B. 1
C. 2
D. 3
Correct answer: A. 0
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Detailed rationale: A score of 0 for Item 1a is assigned when the patient is alert and keenly
responsive. This represents the normal finding in a patient without impaired consciousness. The
NIHSS scoring definition explicitly states that 0 = Alert, keenly responsive.
Why the other options are incorrect:
- A: Correct. This is the score for a fully alert patient.
- B: A score of 1 indicates the patient is not alert but can be aroused by minor stimulation to
obey, answer, or respond.
- C: A score of 2 indicates the patient is not alert and requires repeated stimulation to attend, or
is obtunded.
- D: A score of 3 indicates the patient responds only with reflex motor or autonomic effects or is
totally unresponsive.
Exam tip: Remember the LOC scoring ladder: 0 = Alert; 1 = Arousable with minor stimulation; 2
= Requires repeated/painful stimulation; 3 = Reflex only/unresponsive.
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**Question 2**
**Topic:** Item 1a — Level of Consciousness
**Learning Objective:** Identify the LOC score for a patient who opens eyes only after painful
stimulation.
**Difficulty:** Easy
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**Question:** A patient opens their eyes only after a painful stimulus is applied. The patient
does not follow commands or answer Questions. What LOC score should be assigned?
A. 0
B. 1
C. 2
D. 3
**Correct answer:** C. 2
**Detailed rationale:** A score of 2 is appropriate when the patient is not alert and requires
repeated stimulation to attend or requires strong or painful stimulation to make movements.
Since the patient requires painful stimulation to open the eyes, a score of 2 is correct.
**Why the other options are incorrect:**
- A: Score 0 requires full alertness.
- B: Score 1 requires arousal with minor stimulation, not painful stimulation.
- D: Score 3 indicates no response other than reflex effects.
**Exam tip:** Painful stimulation → Score 2 (unless no response at all → Score 3).
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**Question 3**
