NIHSS LOC Questions and LOC Commands (Items 1b and 1c)

Question 1

For NIHSS item 1b (LOC Questions), the examiner asks the patient two questions. Which pair is correct?

Accepted Answer

What month is it? How old are you?

Answer

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?

Accepted Answer

1 — one answer wrong

Answer

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?

Accepted Answer

Open and close your eyes; make a fist and release (or grip and release)

Answer

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:

Accepted Answer

Substitute another single-step command such as 'open and close your eyes' twice or another single-step non-hand action

Answer

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:

Accepted Answer

Correct — if the intent is clearly the right answer despite dysarthria

Answer

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.

NIHSS - National Institutes of Health Stroke Scale Practice Test

NIHSS - National Institutes of Health Stroke Scale Practice Test

NIHSS LOC Questions and LOC Commands (Items 1b and 1c)