NIHSS LOC Questions and LOC Commands (Items 1b and 1c) — Questions and Answers
Question 1: For NIHSS item 1b (LOC Questions), the examiner asks the patient two questions. Which pair is correct?
- What is today's date? What is the name of this hospital?
- What month is it? How old are you? (Correct answer)
- What year is it? Where are you right now?
- What is your name? What city are we in?
Correct answer: What month is it? How old are you?
The standardized NIHSS protocol specifies exactly two questions: the current month and the patient's age. These specific questions must be used verbatim — substituting other orientation questions is not permitted.
Question 2: A patient answers 'November' when it is July, then correctly states their age. How is item 1b (LOC Questions) scored?
- 0 — both answers correct
- 1 — one answer wrong (Correct answer)
- 2 — both answers wrong
- 1 — the patient was 'close' and partial credit applies
Correct answer: 1 — one answer wrong
Each correct answer reduces the score. The patient got the month wrong but the age correct, so one answer is wrong → score of 1. There is no partial credit for 'close' answers; only exact correctness counts.
Question 3: For NIHSS item 1c (LOC Commands), which two commands must the examiner give?
- Raise your arm; stick out your tongue
- Open and close your eyes; make a fist and release (or grip and release) (Correct answer)
- Squeeze my hand; open your mouth
- Look to the right; then look to the left
Correct answer: Open and close your eyes; make a fist and release (or grip and release)
The NIHSS specifies two commands: (1) open and close the eyes, and (2) make a fist (grip) and release. These exact commands must be used. If the patient cannot use one hand, another single-step command may substitute, but the structure is fixed.
Question 4: A patient with bilateral hand weakness cannot perform the hand grip command for item 1c. The examiner may:
- Mark the item as UN (untestable) and omit it from the score
- Score 2 automatically because neither command can be completed
- Substitute another single-step command such as 'open and close your eyes' twice or another single-step non-hand action (Correct answer)
- Use the leg to perform a kick command as a substitute
Correct answer: Substitute another single-step command such as 'open and close your eyes' twice or another single-step non-hand action
When a patient cannot use their hands, the NIHSS allows substitution with another one-step command. The examiner must document the substitution. The item is not marked UN simply because hand function is impaired.
Question 5: For item 1b (LOC Questions), the examiner asks the patient the month. The patient says the correct month but with a speech impediment that makes it hard to understand. The response is scored as:
- Incorrect — unintelligible responses do not count
- Correct — if the intent is clearly the right answer despite dysarthria (Correct answer)
- 1 — give partial credit for an attempt
- UN — untestable due to speech impairment
Correct answer: Correct — if the intent is clearly the right answer despite dysarthria
LOC Questions (1b) tests orientation, not speech quality. If the examiner can determine that the patient's response is the correct answer despite dysarthria or slurred speech, it is scored as correct. Dysarthria is assessed separately on item 10.
Question 6: On item 1c (LOC Commands), can the examiner pantomime or demonstrate the command if the patient does not respond to verbal instruction alone?
- Yes — pantomime is always permitted to clarify the command
- Yes — but only for Group B patients
- No — the verbal command may be repeated once, but gestures or demonstrations are not allowed (Correct answer)
- No — the command can only be given once and cannot be repeated
Correct answer: No — the verbal command may be repeated once, but gestures or demonstrations are not allowed
The NIHSS protocol permits the verbal command to be repeated once if the patient does not respond. However, pantomiming or physically demonstrating the command is not allowed, as it would bias the assessment of the patient's ability to follow verbal commands.
NIHSS LOC Questions and LOC Commands (Items 1b and 1c)
For NIHSS item 1b (LOC Questions), the examiner asks the patient two questions.
Which pair is correct?