UTHealth Houston
MAXE • SSHIN
★
UTH McGovern Medical School — Department of Neurology
WE MAKE BREAKTHROUGHS HAPPEN
EST. 1972
Comprehensive Guide to NIH Stroke Scale: Sections 1–11
C E RT I F I C AT I O N E X A M I N AT I O N P R E PA R AT I O N
INSTITUTION UTHealth Houston — McGovern Medical COURSE CODE NIHSS-101
School
PROGRAM NIH Stroke Scale Certification ACADEMIC YEAR
EXAM TITLE Comprehensive Guide — Sections 1–11 TOTAL QUESTIONS 44 Questions
CERTIFICATION AHA/ASA NIHSS Certification FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question based on the NIH Stroke Scale protocol.
▸ Scores must reflect what the patient actually does — not what the clinician believes the patient can do.
▸ Scores should never be changed after initial recording.
▸ For intubated, comatose, or amputee patients, record as Untestable (UN) and document the reason.
▸ Correct answers and clinical rationales appear below each question for certification review.
SECTION I — GENERAL PRINCIPLES, LOC, BEST GAZE & VISUAL FIELDS Questions 1 – 44
1. What should be recorded after each subscale exam during the NIH Stroke Scale assessment?
A. The patient's baseline function before the stroke
B. Performance in each category
C. An overall global impression of the patient
D. Only the abnormal findings
CORRECT ANSWER B — Performance in each category
RATIONALE The NIHSS is an 11-item scale (scored 0–42) that requires systematic documentation of performance in each
subscale category immediately after assessment. Each item is scored individually and then summed.
Recording performance per category ensures accuracy, prevents recall bias, and provides a reproducible
neurological assessment that can be tracked over time for clinical decision-making and research purposes.
, 2. When should NIH Stroke Scale scores be changed after initial recording?
A. When the supervising physician disagrees with the score
B. After discussion with the patient's family about baseline function
C. Scores should not be changed after they are recorded
D. At the end of the shift during documentation review
CORRECT ANSWER C — Scores should not be changed after they are recorded
RATIONALE NIHSS protocol explicitly states that scores must never be changed after recording. This preserves the
integrity and reproducibility of the assessment. If an error is suspected, a new assessment should be
performed and documented separately with a new time stamp. Retrospectively altering scores undermines
the validity of serial neurological examinations, compromises treatment decisions (including tPA eligibility),
and introduces bias into clinical trials data.
3. What should NIH Stroke Scale scores reflect?
A. What the clinician thinks the patient can do based on premorbid status
B. What the patient does, not what the clinician thinks the patient can do
C. The patient's best effort after coaching and encouragement
D. An average of the patient's performance over the past 24 hours
CORRECT ANSWER B — Scores should reflect what the patient does, not what the clinician thinks the patient can do
RATIONALE This is a fundamental NIHSS principle. The examiner scores observable performance at the moment of
assessment — not potential, not estimated premorbid function. If the patient cannot or will not perform a
task, they are scored accordingly. Do not coach, cajole, or make allowances. This objective approach
standardizes scoring across examiners and institutions, which is essential for determining tPA eligibility and
monitoring stroke progression.
4. What is the scoring for Alertness (Level of Consciousness — 1a) when the patient is alert and keenly responsive?
A. Score 1
B. Score 2
C. Score 0
D. Score 3
CORRECT ANSWER C — 0 = Alert; keenly responsive
RATIONALE LOC 1a is scored 0 when the patient is alert and responds immediately and appropriately to the examiner's
presence and questions with no stimulation required. Score 1 requires minor stimulation to respond; score 2
requires repeated stimulation or is obtunded; score 3 is reflexive or unresponsive. Level of consciousness is
the first and most fundamental component of the NIHSS as it influences scoring of all subsequent items.
5. What does a score of 1 indicate in Level of Consciousness (1a)?
A. Alert and keenly responsive
B. Not alert; requires repeated stimulation to attend, or is obtunded
C. Not alert; but arousable by minor stimulation to obey, answer, or respond
D. Responds only with reflex motor or autonomic effects, or totally unresponsive
CORRECT ANSWER C — Not alert; but arousable by minor stimulation to obey, answer, or respond
RATIONALE Score 1 indicates the patient is drowsy but can be aroused to full alertness with minimal stimulation (verbal
prompting, light touch). The key distinction from Score 2 is that Score 1 patients, once aroused, can obey
commands and answer questions. Score 2 patients require stronger or repeated stimulation and do not
maintain alertness without continued stimulation.
MAXE • SSHIN
★
UTH McGovern Medical School — Department of Neurology
WE MAKE BREAKTHROUGHS HAPPEN
EST. 1972
Comprehensive Guide to NIH Stroke Scale: Sections 1–11
C E RT I F I C AT I O N E X A M I N AT I O N P R E PA R AT I O N
INSTITUTION UTHealth Houston — McGovern Medical COURSE CODE NIHSS-101
School
PROGRAM NIH Stroke Scale Certification ACADEMIC YEAR
EXAM TITLE Comprehensive Guide — Sections 1–11 TOTAL QUESTIONS 44 Questions
CERTIFICATION AHA/ASA NIHSS Certification FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question based on the NIH Stroke Scale protocol.
▸ Scores must reflect what the patient actually does — not what the clinician believes the patient can do.
▸ Scores should never be changed after initial recording.
▸ For intubated, comatose, or amputee patients, record as Untestable (UN) and document the reason.
▸ Correct answers and clinical rationales appear below each question for certification review.
SECTION I — GENERAL PRINCIPLES, LOC, BEST GAZE & VISUAL FIELDS Questions 1 – 44
1. What should be recorded after each subscale exam during the NIH Stroke Scale assessment?
A. The patient's baseline function before the stroke
B. Performance in each category
C. An overall global impression of the patient
D. Only the abnormal findings
CORRECT ANSWER B — Performance in each category
RATIONALE The NIHSS is an 11-item scale (scored 0–42) that requires systematic documentation of performance in each
subscale category immediately after assessment. Each item is scored individually and then summed.
Recording performance per category ensures accuracy, prevents recall bias, and provides a reproducible
neurological assessment that can be tracked over time for clinical decision-making and research purposes.
, 2. When should NIH Stroke Scale scores be changed after initial recording?
A. When the supervising physician disagrees with the score
B. After discussion with the patient's family about baseline function
C. Scores should not be changed after they are recorded
D. At the end of the shift during documentation review
CORRECT ANSWER C — Scores should not be changed after they are recorded
RATIONALE NIHSS protocol explicitly states that scores must never be changed after recording. This preserves the
integrity and reproducibility of the assessment. If an error is suspected, a new assessment should be
performed and documented separately with a new time stamp. Retrospectively altering scores undermines
the validity of serial neurological examinations, compromises treatment decisions (including tPA eligibility),
and introduces bias into clinical trials data.
3. What should NIH Stroke Scale scores reflect?
A. What the clinician thinks the patient can do based on premorbid status
B. What the patient does, not what the clinician thinks the patient can do
C. The patient's best effort after coaching and encouragement
D. An average of the patient's performance over the past 24 hours
CORRECT ANSWER B — Scores should reflect what the patient does, not what the clinician thinks the patient can do
RATIONALE This is a fundamental NIHSS principle. The examiner scores observable performance at the moment of
assessment — not potential, not estimated premorbid function. If the patient cannot or will not perform a
task, they are scored accordingly. Do not coach, cajole, or make allowances. This objective approach
standardizes scoring across examiners and institutions, which is essential for determining tPA eligibility and
monitoring stroke progression.
4. What is the scoring for Alertness (Level of Consciousness — 1a) when the patient is alert and keenly responsive?
A. Score 1
B. Score 2
C. Score 0
D. Score 3
CORRECT ANSWER C — 0 = Alert; keenly responsive
RATIONALE LOC 1a is scored 0 when the patient is alert and responds immediately and appropriately to the examiner's
presence and questions with no stimulation required. Score 1 requires minor stimulation to respond; score 2
requires repeated stimulation or is obtunded; score 3 is reflexive or unresponsive. Level of consciousness is
the first and most fundamental component of the NIHSS as it influences scoring of all subsequent items.
5. What does a score of 1 indicate in Level of Consciousness (1a)?
A. Alert and keenly responsive
B. Not alert; requires repeated stimulation to attend, or is obtunded
C. Not alert; but arousable by minor stimulation to obey, answer, or respond
D. Responds only with reflex motor or autonomic effects, or totally unresponsive
CORRECT ANSWER C — Not alert; but arousable by minor stimulation to obey, answer, or respond
RATIONALE Score 1 indicates the patient is drowsy but can be aroused to full alertness with minimal stimulation (verbal
prompting, light touch). The key distinction from Score 2 is that Score 1 patients, once aroused, can obey
commands and answer questions. Score 2 patients require stronger or repeated stimulation and do not
maintain alertness without continued stimulation.
