APEX NIH STROKE SCALE – GROUP B
(PATIENT 1–6) PRACTICE EXAM WITH
ANSWERS AND RATIONALES
(ADVENTHEALTH 2025/2026)
Introduction
This AdventHealth-aligned practice set for NIHSS Group B (Patients 1–6) follows
2025/2026 APEX certification standards, using the official NIHSS scale for acute stroke
assessment. Each case simulates video-based evaluation with realistic deficits, full item
scoring, and rationales based on NIHSS criteria (e.g., LOC arousal, motor drift timing).
Total scores guide severity: 0–4 mild, 5–15 moderate, 16–20 moderate-severe, 21–42
severe. Review AHA/ASA guidelines for tPA eligibility (NIHSS >4 often).
Patient [1] Scenario: Left Middle Cerebral Artery (MCA) Stroke Simulation
Clinical Summary: A 68-year-old right-handed male presents with sudden onset of right
facial droop, slurred speech, and weakness in the right arm and leg. He is alert but has
difficulty naming objects and following complex commands. Gaze is deviated to the left,
with right homonymous hemianopia. No ataxia or sensory complaints noted. Symptoms
started 2 hours ago.
NIH Stroke Scale Evaluation
| NIHSS Item | Description | Correct Score | Rationale |
|||||
| 1a. Level of Consciousness | Alert, responds to voice but drowsy | 1 | Mildly drowsy but
arousable; score 1 for reduced alertness per NIHSS (0 alert, 2 stupor).
| 1b. LOC Questions | Answers 1/2 questions correctly (month wrong, age correct) | 1 |
Partial disorientation; 1 for 1/2 correct (0 both, 2 none).
| 1c. LOC Commands | Performs 1/2 commands (closes eyes, not fist) | 1 | Aphasia
affects; 1 for 1/2 (0 both, 2 none).
| 2. Best Gaze | Conjugate deviation to left, partial correction with doll's eyes | 1 | Partial
deviation; 1 for abnormal but correctable (0 normal, 2 forced).
| 3. Visual Fields | Right homonymous hemianopia | 2 | Complete hemianopia; 2 for full
field cut (0 normal, 1 partial).
, | 4. Facial Palsy | Moderate right lower face weakness | 2 | Partial paralysis; 2 for
moderate (0 normal, 1 minor, 3 complete).
| 5a. Motor Arm (Left) | Normal hold, no drift | 0 | Full strength; 0 normal (1 drift, 2 effort, 4
none).
| 5b. Motor Arm (Right) | Drift, hits bed in 10 seconds | 1 | Mild weakness; 1 drift (0 no, 2
against gravity, 4 flaccid).
| 6a. Motor Leg (Left) | No drift | 0 | Full strength; 0 normal.
| 6b. Motor Leg (Right) | Holds 90 degrees, slight drift | 1 | Mild weakness; 1 drift.
| 7. Limb Ataxia | Absent | 0 | No dysmetria; 0 absent (1 present, 2 severe).
| 8. Sensory | Mild right hemisensory loss | 1 | Mild loss; 1 mild (0 normal, 2 severe).
| 9. Best Language | Moderate aphasia, names 1/3 objects | 2 | Moderate impairment; 2
moderate (0 normal, 1 mild, 3 severe).
| 10. Dysarthria | Mild slurring | 1 | Mild; 1 mild (0 normal, 2 severe).
| 11. Extinction and Inattention | Right neglect | 1 | Mild inattention; 1 mild (0 normal, 2
profound).
Total NIHSS Score: 11
Interpretation: Moderate stroke (5–15); indicates left MCA involvement with aphasia and
right hemiparesis, warranting urgent imaging/tPA consideration per AHA guidelines.
Patient [2] Scenario: Pontine (Brainstem) Stroke Simulation
Clinical Summary: A 72-year-old female arrives with sudden vertigo, horizontal
nystagmus, and left facial weakness. She is alert but has dysarthria and left hemiparesis.
No hemianopia or neglect. Commands followed with effort. Symptoms 90 minutes ago,
witnessed.
NIH Stroke Scale Evaluation
| NIHSS Item | Description | Correct Score | Rationale |
|||||
| 1a. Level of Consciousness | Alert | 0 | Fully responsive; 0 alert.
| 1b. LOC Questions | Both correct | 0 | Oriented; 0 both.
| 1c. LOC Commands | Both performed | 0 | Normal; 0 both.
| 2. Best Gaze | Horizontal nystagmus, conjugate | 0 | Nystagmus not deviation; 0 normal
(1 partial, 2 forced).
| 3. Visual Fields | Normal | 0 | Full fields; 0 normal.
| 4. Facial Palsy | Mild left lower weakness | 1 | Minor asymmetry; 1 minor (0 normal, 2
moderate, 3 complete).
| 5a. Motor Arm (Left) | Drift, effort against gravity | 2 | Moderate weakness; 2 some effort
(0 no drift, 1 drift, 4 none).
(PATIENT 1–6) PRACTICE EXAM WITH
ANSWERS AND RATIONALES
(ADVENTHEALTH 2025/2026)
Introduction
This AdventHealth-aligned practice set for NIHSS Group B (Patients 1–6) follows
2025/2026 APEX certification standards, using the official NIHSS scale for acute stroke
assessment. Each case simulates video-based evaluation with realistic deficits, full item
scoring, and rationales based on NIHSS criteria (e.g., LOC arousal, motor drift timing).
Total scores guide severity: 0–4 mild, 5–15 moderate, 16–20 moderate-severe, 21–42
severe. Review AHA/ASA guidelines for tPA eligibility (NIHSS >4 often).
Patient [1] Scenario: Left Middle Cerebral Artery (MCA) Stroke Simulation
Clinical Summary: A 68-year-old right-handed male presents with sudden onset of right
facial droop, slurred speech, and weakness in the right arm and leg. He is alert but has
difficulty naming objects and following complex commands. Gaze is deviated to the left,
with right homonymous hemianopia. No ataxia or sensory complaints noted. Symptoms
started 2 hours ago.
NIH Stroke Scale Evaluation
| NIHSS Item | Description | Correct Score | Rationale |
|||||
| 1a. Level of Consciousness | Alert, responds to voice but drowsy | 1 | Mildly drowsy but
arousable; score 1 for reduced alertness per NIHSS (0 alert, 2 stupor).
| 1b. LOC Questions | Answers 1/2 questions correctly (month wrong, age correct) | 1 |
Partial disorientation; 1 for 1/2 correct (0 both, 2 none).
| 1c. LOC Commands | Performs 1/2 commands (closes eyes, not fist) | 1 | Aphasia
affects; 1 for 1/2 (0 both, 2 none).
| 2. Best Gaze | Conjugate deviation to left, partial correction with doll's eyes | 1 | Partial
deviation; 1 for abnormal but correctable (0 normal, 2 forced).
| 3. Visual Fields | Right homonymous hemianopia | 2 | Complete hemianopia; 2 for full
field cut (0 normal, 1 partial).
, | 4. Facial Palsy | Moderate right lower face weakness | 2 | Partial paralysis; 2 for
moderate (0 normal, 1 minor, 3 complete).
| 5a. Motor Arm (Left) | Normal hold, no drift | 0 | Full strength; 0 normal (1 drift, 2 effort, 4
none).
| 5b. Motor Arm (Right) | Drift, hits bed in 10 seconds | 1 | Mild weakness; 1 drift (0 no, 2
against gravity, 4 flaccid).
| 6a. Motor Leg (Left) | No drift | 0 | Full strength; 0 normal.
| 6b. Motor Leg (Right) | Holds 90 degrees, slight drift | 1 | Mild weakness; 1 drift.
| 7. Limb Ataxia | Absent | 0 | No dysmetria; 0 absent (1 present, 2 severe).
| 8. Sensory | Mild right hemisensory loss | 1 | Mild loss; 1 mild (0 normal, 2 severe).
| 9. Best Language | Moderate aphasia, names 1/3 objects | 2 | Moderate impairment; 2
moderate (0 normal, 1 mild, 3 severe).
| 10. Dysarthria | Mild slurring | 1 | Mild; 1 mild (0 normal, 2 severe).
| 11. Extinction and Inattention | Right neglect | 1 | Mild inattention; 1 mild (0 normal, 2
profound).
Total NIHSS Score: 11
Interpretation: Moderate stroke (5–15); indicates left MCA involvement with aphasia and
right hemiparesis, warranting urgent imaging/tPA consideration per AHA guidelines.
Patient [2] Scenario: Pontine (Brainstem) Stroke Simulation
Clinical Summary: A 72-year-old female arrives with sudden vertigo, horizontal
nystagmus, and left facial weakness. She is alert but has dysarthria and left hemiparesis.
No hemianopia or neglect. Commands followed with effort. Symptoms 90 minutes ago,
witnessed.
NIH Stroke Scale Evaluation
| NIHSS Item | Description | Correct Score | Rationale |
|||||
| 1a. Level of Consciousness | Alert | 0 | Fully responsive; 0 alert.
| 1b. LOC Questions | Both correct | 0 | Oriented; 0 both.
| 1c. LOC Commands | Both performed | 0 | Normal; 0 both.
| 2. Best Gaze | Horizontal nystagmus, conjugate | 0 | Nystagmus not deviation; 0 normal
(1 partial, 2 forced).
| 3. Visual Fields | Normal | 0 | Full fields; 0 normal.
| 4. Facial Palsy | Mild left lower weakness | 1 | Minor asymmetry; 1 minor (0 normal, 2
moderate, 3 complete).
| 5a. Motor Arm (Left) | Drift, effort against gravity | 2 | Moderate weakness; 2 some effort
(0 no drift, 1 drift, 4 none).
