NIHSS Certification Practice Exam (Group B
Style), covering 300 original multiple-choice
questions with answers and explanations
SECTION I: GENERAL PRINCIPLES, ADMINISTRATION & SCORING RULES (Questions
1–40)
Question 1. What is the maximum possible score on the NIH Stroke Scale (NIHSS)?
A. 36
D
B. 42
C. 48
O
D. 30
N
Answer: B
O
Explanation: The NIHSS ranges from 0 (no stroke symptoms) to 42 (severe stroke). This maximum
T
score is derived from summing the highest possible scores across all 11 items, including bilateral limb
C
scoring for motor arm and motor leg.
O
PY
Question 2. In what order should the NIHSS items be administered?
A. In the order listed, without going back to change scores
B. Starting with the most severe deficits
C. In any order, as long as all items are completed
D. Motor items first, followed by language items
Answer: A
Explanation: The NIHSS instructions explicitly state that items should be administered in the order
listed. Clinicians should not go back and change scores once the examination has progressed.
Question 3. Which of the following is a core scoring principle of the NIHSS?
A. Score based on what the patient should be able to do
B. Score the best response the patient can achieve
,C. Score what you see, not what you think
D. Coach the patient to maximize performance
Answer: C
Explanation: A fundamental NIHSS rule is to "score what you see, not what you think." Clinicians
must score based on the patient's actual performance, not on assumptions about their capabilities.
Question 4. For most NIHSS items, which response should be scored?
A. The best response
B. The first response
C. The average of multiple attempts
D. The response after coaching
Answer: B
D
Explanation: The NIHSS requires scoring the first response, not the best response. The exception is
O
Item 9 (Best Language), where the best language performance is scored.
N
O
Question 5. During NIHSS administration, when is coaching the patient permitted?
T
A. Always
C
B. Never, unless the instructions explicitly allow it
O
C. Only for motor items
PY
D. Only for language items
Answer: B
Explanation: Clinicians must never assist or coach the patient during the NIHSS examination unless
the specific item instructions explicitly allow it (e.g., pantomiming for commands).
Question 6. How does the NIHSS handle preexisting neurological deficits?
A. Preexisting deficits are always excluded from scoring
B. Preexisting deficits are scored except for sensory impairments
C. Preexisting deficits are only scored if they are severe
D. Preexisting deficits are never scored
,Answer: B
Explanation: The NIHSS instructs that preexisting deficits should be scored, with the exception of
sensory impairments. This ensures the scale captures the patient's current neurological status.
Question 7. Which of the following is TRUE regarding the NIHSS and thrombolytic eligibility?
A. The NIHSS score is the sole determinant of IV alteplase eligibility
B. A low NIHSS score always excludes thrombolysis
C. The NIHSS quantifies severity but should not be the sole determinant of IV alteplase eligibility
D. Only patients with NIHSS > 10 are eligible for thrombolysis
Answer: C
Explanation: The NIHSS quantifies stroke severity but should not be used as the sole determinant of
IV alteplase eligibility. Patients with mild but disabling symptoms (e.g., aphasia, hemiparesis) should
D
still be considered for tPA.
O
N
Question 8. Approximately how long does NIHSS administration typically take in the acute setting?
O
A. 2–3 minutes
T
B. 5–10 minutes
C
C. 20–30 minutes
D. 45–60 minutes
O
PY
Answer: B
Explanation: The NIHSS typically requires 5–10 minutes to administer in the acute setting.
Question 9. Who is qualified to administer the NIHSS?
A. Only neurologists
B. Only physicians
C. Any trained and certified health professional
D. Only stroke nurse specialists
Answer: C
Explanation: Any trained and certified health professional—including physicians, nurses, therapists,
and social workers—may administer the NIHSS.
, Question 10. Which of the following is a rule for scoring Item 1a (Level of Consciousness) when a
full evaluation is prevented by an endotracheal tube?
A. Score 0
B. Score 3
C. The investigator must choose a response
D. Skip the item entirely
Answer: C
Explanation: If a full evaluation is prevented by obstacles such as an endotracheal tube, language
barrier, or orotracheal trauma/bandages, the investigator must choose a response. A score of 3 is
reserved only for patients who make no movement (other than reflexive posturing) in response to
noxious stimulation.
D
Question 11. What is the significance of an NIHSS score ≥ 9 within 3 hours of symptom onset?
O
A. It predicts a benign course
B. It is a cutoff value for predicting large vessel occlusion (LVO)
N
C. It contraindicates thrombolysis
O
D. It indicates a lacunar infarct
T
Answer: B
C
Explanation: NIHSS scores ≥ 9 within 3 hours and ≥ 7 within 3–6 hours have been reported as
O
cutoffs for predicting large vessel occlusion (LVO).
PY
Question 12. An NIHSS score of less than 6 is most predictive of:
A. High likelihood of death
B. Good functional recovery
C. Large vessel occlusion
D. Hemorrhagic transformation
Answer: B
Explanation: A score < 6 predicts good functional recovery. Scores > 16 forecast a high probability
of death or severe disability.
Question 13. Which NIHSS item is scored based on the "best" response rather than the first response?
Style), covering 300 original multiple-choice
questions with answers and explanations
SECTION I: GENERAL PRINCIPLES, ADMINISTRATION & SCORING RULES (Questions
1–40)
Question 1. What is the maximum possible score on the NIH Stroke Scale (NIHSS)?
A. 36
D
B. 42
C. 48
O
D. 30
N
Answer: B
O
Explanation: The NIHSS ranges from 0 (no stroke symptoms) to 42 (severe stroke). This maximum
T
score is derived from summing the highest possible scores across all 11 items, including bilateral limb
C
scoring for motor arm and motor leg.
O
PY
Question 2. In what order should the NIHSS items be administered?
A. In the order listed, without going back to change scores
B. Starting with the most severe deficits
C. In any order, as long as all items are completed
D. Motor items first, followed by language items
Answer: A
Explanation: The NIHSS instructions explicitly state that items should be administered in the order
listed. Clinicians should not go back and change scores once the examination has progressed.
Question 3. Which of the following is a core scoring principle of the NIHSS?
A. Score based on what the patient should be able to do
B. Score the best response the patient can achieve
,C. Score what you see, not what you think
D. Coach the patient to maximize performance
Answer: C
Explanation: A fundamental NIHSS rule is to "score what you see, not what you think." Clinicians
must score based on the patient's actual performance, not on assumptions about their capabilities.
Question 4. For most NIHSS items, which response should be scored?
A. The best response
B. The first response
C. The average of multiple attempts
D. The response after coaching
Answer: B
D
Explanation: The NIHSS requires scoring the first response, not the best response. The exception is
O
Item 9 (Best Language), where the best language performance is scored.
N
O
Question 5. During NIHSS administration, when is coaching the patient permitted?
T
A. Always
C
B. Never, unless the instructions explicitly allow it
O
C. Only for motor items
PY
D. Only for language items
Answer: B
Explanation: Clinicians must never assist or coach the patient during the NIHSS examination unless
the specific item instructions explicitly allow it (e.g., pantomiming for commands).
Question 6. How does the NIHSS handle preexisting neurological deficits?
A. Preexisting deficits are always excluded from scoring
B. Preexisting deficits are scored except for sensory impairments
C. Preexisting deficits are only scored if they are severe
D. Preexisting deficits are never scored
,Answer: B
Explanation: The NIHSS instructs that preexisting deficits should be scored, with the exception of
sensory impairments. This ensures the scale captures the patient's current neurological status.
Question 7. Which of the following is TRUE regarding the NIHSS and thrombolytic eligibility?
A. The NIHSS score is the sole determinant of IV alteplase eligibility
B. A low NIHSS score always excludes thrombolysis
C. The NIHSS quantifies severity but should not be the sole determinant of IV alteplase eligibility
D. Only patients with NIHSS > 10 are eligible for thrombolysis
Answer: C
Explanation: The NIHSS quantifies stroke severity but should not be used as the sole determinant of
IV alteplase eligibility. Patients with mild but disabling symptoms (e.g., aphasia, hemiparesis) should
D
still be considered for tPA.
O
N
Question 8. Approximately how long does NIHSS administration typically take in the acute setting?
O
A. 2–3 minutes
T
B. 5–10 minutes
C
C. 20–30 minutes
D. 45–60 minutes
O
PY
Answer: B
Explanation: The NIHSS typically requires 5–10 minutes to administer in the acute setting.
Question 9. Who is qualified to administer the NIHSS?
A. Only neurologists
B. Only physicians
C. Any trained and certified health professional
D. Only stroke nurse specialists
Answer: C
Explanation: Any trained and certified health professional—including physicians, nurses, therapists,
and social workers—may administer the NIHSS.
, Question 10. Which of the following is a rule for scoring Item 1a (Level of Consciousness) when a
full evaluation is prevented by an endotracheal tube?
A. Score 0
B. Score 3
C. The investigator must choose a response
D. Skip the item entirely
Answer: C
Explanation: If a full evaluation is prevented by obstacles such as an endotracheal tube, language
barrier, or orotracheal trauma/bandages, the investigator must choose a response. A score of 3 is
reserved only for patients who make no movement (other than reflexive posturing) in response to
noxious stimulation.
D
Question 11. What is the significance of an NIHSS score ≥ 9 within 3 hours of symptom onset?
O
A. It predicts a benign course
B. It is a cutoff value for predicting large vessel occlusion (LVO)
N
C. It contraindicates thrombolysis
O
D. It indicates a lacunar infarct
T
Answer: B
C
Explanation: NIHSS scores ≥ 9 within 3 hours and ≥ 7 within 3–6 hours have been reported as
O
cutoffs for predicting large vessel occlusion (LVO).
PY
Question 12. An NIHSS score of less than 6 is most predictive of:
A. High likelihood of death
B. Good functional recovery
C. Large vessel occlusion
D. Hemorrhagic transformation
Answer: B
Explanation: A score < 6 predicts good functional recovery. Scores > 16 forecast a high probability
of death or severe disability.
Question 13. Which NIHSS item is scored based on the "best" response rather than the first response?
