NIH Stroke Scale (NIHSS) Group D Certification Test -
Patient 1-6 Scoring Guide
Section 1: General NIHSS Knowledge
1. The maximum score on the NIH Stroke Scale is:
A) 36
B) 42
C) 24
D) 15
Answer: B) 42
Rationale: The NIHSS has 15 items (with subparts for motor arms and legs) and a
maximum total score of 42. The score correlates with stroke severity, with higher scores
indicating more severe deficits.
2. Which item on the NIHSS is scored based on the patient's response to two
specific questions (month and age)?
A) 1a Level of Consciousness
B) 1b LOC Questions
C) 1c LOC Commands
D) 2 Best Gaze
Answer: B) 1b LOC Questions
Rationale: Item 1b asks the patient to state the current month and their age. Score 0 if
both correct, 1 if one correct, and 2 if neither is correct.
3. For the LOC Commands (item 1c), what are the two standard commands?
A) Open/close eyes and make a fist
B) Stick out tongue and say "ah"
,C) Open/close eyes and grip/release hand
D) Point to the ceiling and show two fingers
Answer: C) Open/close eyes and grip/release hand
Rationale: The standard commands are: "Open and close your eyes" and "Grip and release
my hand." The patient must perform both correctly to score 0.
4. A patient who does not follow commands but makes a purposeful attempt to
withdraw from a painful stimulus scores what on item 1a (Level of Consciousness)?
A) 0
B) 1
C) 2
D) 3
Answer: B) 1
Rationale: Item 1a scoring: 0 = alert, 1 = not alert but arousable by minor stimulation, 2 =
requires repeated stimulation or obtunded, 3 = unresponsive or only reflex movements. A
purposeful withdrawal indicates some responsiveness.
5. When testing visual fields (item 3), the examiner should perform:
A) Full confrontation with finger counting in all four quadrants
B) Only the left eye
C) Only central vision
D) A dilated fundoscopic exam
Answer: A) Full confrontation with finger counting in all four quadrants
Rationale: Visual fields are tested by confrontation with finger counting or wiggle in each
quadrant separately. The patient must count fingers or detect movement in all four
quadrants.
6. Which of the following is NOT a required category on the NIHSS?
A) Pupillary reactivity
,B) Facial palsy
C) Limb ataxia
D) Dysarthria
Answer: A) Pupillary reactivity
Rationale: Pupillary reactivity is not part of the NIHSS; it is part of the Glasgow Coma
Scale or other neurological exams. The NIHSS includes 11 main categories but not
pupillary response.
7. The sensory item (item 8) tests for:
A) Pain and temperature
B) Light touch and pinprick
C) Vibration and proprioception
D) Two-point discrimination
Answer: B) Light touch and pinprick
Rationale: Sensory testing uses pinprick or light touch on the face, arm, trunk, and leg.
Score 0 = normal, 1 = mild loss, 2 = severe loss.
8. In the NIHSS, the term "dysarthria" refers to:
A) Difficulty understanding language
B) Difficulty producing speech due to motor problems
C) Difficulty finding words
D) Loss of voice
Answer: B) Difficulty producing speech due to motor problems
Rationale: Dysarthria is a motor speech disorder caused by weakness or incoordination of
the muscles used for speech. Aphasia (item 9) is the language disorder involving
comprehension or word-finding.
9. Limb ataxia (item 7) is scored only if:
A) The patient has sensory loss
, B) The patient is aphasic
C) The patient has a visual field cut
D) The finding is out of proportion to weakness
Answer: D) The finding is out of proportion to weakness
Rationale: Ataxia is scored only when present and not due to weakness or sensory loss. If
the patient cannot perform the task due to weakness, the item is scored 0.
10. A patient who is unable to perform the finger-nose-finger test due to
weakness in the limb should receive a limb ataxia score of:
A) 0
B) 1
C) 2
D) 3
Answer: A) 0
Rationale: Ataxia is not assessed if weakness interferes with the ability to perform the test;
score 0.
11. For motor arm testing (item 5), if the patient cannot maintain the arm position
for the full 10 seconds, the score is:
A) 0
B) 1
C) 2
D) 3
Answer: B) 1
Rationale: Item 5 scoring: 0 = no drift, 1 = drift before 10 seconds but not hitting bed, 2 =
drifts to bed within 10 seconds, 3 = no effort against gravity, 4 = no movement.
12. The motor arm (item 5) and motor leg (item 6) are tested with the patient
lying in which position?
Patient 1-6 Scoring Guide
Section 1: General NIHSS Knowledge
1. The maximum score on the NIH Stroke Scale is:
A) 36
B) 42
C) 24
D) 15
Answer: B) 42
Rationale: The NIHSS has 15 items (with subparts for motor arms and legs) and a
maximum total score of 42. The score correlates with stroke severity, with higher scores
indicating more severe deficits.
2. Which item on the NIHSS is scored based on the patient's response to two
specific questions (month and age)?
A) 1a Level of Consciousness
B) 1b LOC Questions
C) 1c LOC Commands
D) 2 Best Gaze
Answer: B) 1b LOC Questions
Rationale: Item 1b asks the patient to state the current month and their age. Score 0 if
both correct, 1 if one correct, and 2 if neither is correct.
3. For the LOC Commands (item 1c), what are the two standard commands?
A) Open/close eyes and make a fist
B) Stick out tongue and say "ah"
,C) Open/close eyes and grip/release hand
D) Point to the ceiling and show two fingers
Answer: C) Open/close eyes and grip/release hand
Rationale: The standard commands are: "Open and close your eyes" and "Grip and release
my hand." The patient must perform both correctly to score 0.
4. A patient who does not follow commands but makes a purposeful attempt to
withdraw from a painful stimulus scores what on item 1a (Level of Consciousness)?
A) 0
B) 1
C) 2
D) 3
Answer: B) 1
Rationale: Item 1a scoring: 0 = alert, 1 = not alert but arousable by minor stimulation, 2 =
requires repeated stimulation or obtunded, 3 = unresponsive or only reflex movements. A
purposeful withdrawal indicates some responsiveness.
5. When testing visual fields (item 3), the examiner should perform:
A) Full confrontation with finger counting in all four quadrants
B) Only the left eye
C) Only central vision
D) A dilated fundoscopic exam
Answer: A) Full confrontation with finger counting in all four quadrants
Rationale: Visual fields are tested by confrontation with finger counting or wiggle in each
quadrant separately. The patient must count fingers or detect movement in all four
quadrants.
6. Which of the following is NOT a required category on the NIHSS?
A) Pupillary reactivity
,B) Facial palsy
C) Limb ataxia
D) Dysarthria
Answer: A) Pupillary reactivity
Rationale: Pupillary reactivity is not part of the NIHSS; it is part of the Glasgow Coma
Scale or other neurological exams. The NIHSS includes 11 main categories but not
pupillary response.
7. The sensory item (item 8) tests for:
A) Pain and temperature
B) Light touch and pinprick
C) Vibration and proprioception
D) Two-point discrimination
Answer: B) Light touch and pinprick
Rationale: Sensory testing uses pinprick or light touch on the face, arm, trunk, and leg.
Score 0 = normal, 1 = mild loss, 2 = severe loss.
8. In the NIHSS, the term "dysarthria" refers to:
A) Difficulty understanding language
B) Difficulty producing speech due to motor problems
C) Difficulty finding words
D) Loss of voice
Answer: B) Difficulty producing speech due to motor problems
Rationale: Dysarthria is a motor speech disorder caused by weakness or incoordination of
the muscles used for speech. Aphasia (item 9) is the language disorder involving
comprehension or word-finding.
9. Limb ataxia (item 7) is scored only if:
A) The patient has sensory loss
, B) The patient is aphasic
C) The patient has a visual field cut
D) The finding is out of proportion to weakness
Answer: D) The finding is out of proportion to weakness
Rationale: Ataxia is scored only when present and not due to weakness or sensory loss. If
the patient cannot perform the task due to weakness, the item is scored 0.
10. A patient who is unable to perform the finger-nose-finger test due to
weakness in the limb should receive a limb ataxia score of:
A) 0
B) 1
C) 2
D) 3
Answer: A) 0
Rationale: Ataxia is not assessed if weakness interferes with the ability to perform the test;
score 0.
11. For motor arm testing (item 5), if the patient cannot maintain the arm position
for the full 10 seconds, the score is:
A) 0
B) 1
C) 2
D) 3
Answer: B) 1
Rationale: Item 5 scoring: 0 = no drift, 1 = drift before 10 seconds but not hitting bed, 2 =
drifts to bed within 10 seconds, 3 = no effort against gravity, 4 = no movement.
12. The motor arm (item 5) and motor leg (item 6) are tested with the patient
lying in which position?
