NIH Stroke Scale (NIHSS) Certification — Questions and Answers

Question 1: A patient with NIHSS Item 1a score of 3 would most likely present as:

Showing only reflex posturing or autonomic responses to stimuli (Correct answer)
Drowsy but responding to voice
Lethargic but opening eyes to touch
Making purposeful movements to painful stimulation

Correct answer: Showing only reflex posturing or autonomic responses to stimuli

A score of 3 on Item 1a means the patient responds only with reflex motor or autonomic effects, or is totally unresponsive.

Question 2: In NIHSS training, which patient behavior during the language assessment would NOT be counted as aphasia?

Unable to repeat the phrase 'no ifs, ands, or buts'
Substituting a semantically related word (e.g., 'chair' for 'table')
Slurred but intelligible speech when naming objects (Correct answer)
Describing the cookie theft picture with only 2 words

Correct answer: Slurred but intelligible speech when naming objects

Slurred but intelligible speech reflects dysarthria (Item 10), not aphasia (Item 9), so it does not increase the language score.

Question 3: Which NIHSS score range indicates a moderate stroke?

5-15 (Correct answer)
12-18
1-4
3-10

Correct answer: 5-15

NIHSS scores of 5-15 classify a stroke as moderate, indicating significant but not catastrophic neurological impairment.

Question 4: A nurse asks whether the NIHSS LOC section can be skipped if the patient is clearly alert. The correct response is:

Yes, Item 1a can be skipped but 1b and 1c must be done
Yes, all LOC items can be skipped for alert patients to save time
Only Item 1c can be skipped for alert patients
No, all three LOC items must be completed and documented for every assessment (Correct answer)

Correct answer: No, all three LOC items must be completed and documented for every assessment

All NIHSS items including 1a, 1b, and 1c must be completed and documented for every formal assessment regardless of apparent alertness.

Question 5: A patient is drowsy but withdraws from pinprick on both sides. What NIHSS sensory score applies?

2 — withdrawal in drowsy patients means severe loss
Score cannot be determined in drowsy patients
1 — drowsy patients automatically receive score 1
0 — bilateral withdrawal indicates normal sensation (Correct answer)

Correct answer: 0 — bilateral withdrawal indicates normal sensation

Symmetric bilateral withdrawal from pinprick in a drowsy patient indicates intact sensation bilaterally, scoring 0.

Question 6: Which NIHSS item directly tests the patient's ability to read and name objects from a standardized card set?

Item 9 — Language (Correct answer)
Item 11 — Extinction
Item 10 — Dysarthria
Item 8 — Sensory

Correct answer: Item 9 — Language

NIHSS Item 9 assesses language using a picture description task, object naming card, and reading sentences from a standardized card.

Question 7: The NIHSS was originally developed primarily for use in which context?

Clinical trials and stroke research (Correct answer)
Primary care annual screening
Inpatient rehabilitation planning
Emergency triage protocols

Correct answer: Clinical trials and stroke research

The NIHSS was developed in 1989 as a standardized tool for clinical stroke trials to allow consistent, reproducible measurement of neurological status.

Question 8: During NIHSS assessment, which of the following best describes a score of 1 on Item 1a (Level of Consciousness)?

Patient is unresponsive to all stimuli
Patient is fully awake and responds normally
Patient requires noxious stimulation to make any movement
Patient is not alert but responds to minor stimulation such as voice or touch (Correct answer)

Correct answer: Patient is not alert but responds to minor stimulation such as voice or touch

A score of 1 indicates the patient is not fully alert but can be aroused by minor stimulation like voice or light touch.

Question 9: When performing NIHSS sensory testing, which tool is the standard stimulus used to assess sensation?

Tuning fork
Monofilament
Cotton wisp
Pinprick or broken wooden applicator (Correct answer)

Correct answer: Pinprick or broken wooden applicator

A pinprick or the sharp end of a broken wooden applicator stick is the standard stimulus for NIHSS sensory testing.

Question 10: Which NIHSS item specifically evaluates the patient's ability to name objects and read sentences?

Extinction and Inattention (Item 11)
Dysarthria (Item 10)
Best Language (Item 9) (Correct answer)
Level of Consciousness Commands (Item 1b)

Correct answer: Best Language (Item 9)

Best Language (Item 9) assesses naming, reading, and comprehension to evaluate aphasia severity.

Question 11: A patient correctly answers what month it is but cannot state their age. How is Item 1b scored?

1 - only one question answered correctly (Correct answer)
2 - the patient failed the primary question
The item is deferred
0 - one correct is sufficient for a perfect score

Correct answer: 1 - only one question answered correctly

Answering only one of the two orientation questions correctly yields a score of 1 on Item 1b.

Question 12: A patient opens their eyes only when the examiner applies a painful stimulus. How is their level of consciousness scored on NIHSS Item 1a?

3 - Responds only with reflex motor or autonomic effects
1 - Not alert but arousable by minor stimulation
0 - Alert
2 - Not alert, requires repeated or painful stimulation (Correct answer)

Correct answer: 2 - Not alert, requires repeated or painful stimulation

A patient requiring painful stimulation to respond scores a 2 on NIHSS Item 1a.

Question 13: Which of the following best describes an internuclear ophthalmoplegia (INO) and its NIHSS Best Gaze score?

Impaired adduction of one eye on lateral gaze; scores 1 (Correct answer)
Forced contralateral deviation; scores 2
Loss of both upward and downward gaze; scores 2
Normal horizontal gaze; scores 0

Correct answer: Impaired adduction of one eye on lateral gaze; scores 1

INO causes impaired adduction of the ipsilateral eye on lateral gaze, representing a partial gaze abnormality that scores 1.

Question 14: In the Group A patient assessment, the patient has cerebellar ataxia but is also hemiplegic on the same side. How should Item 7 (Limb Ataxia) be scored for the hemiplegic limb?

Score as 2 — both limbs affected
Score as NT — not testable
Score based on the ataxia observed
Score as 0 — not scored in hemiplegic limb (Correct answer)

Correct answer: Score as 0 — not scored in hemiplegic limb

Limb ataxia is only scored if present and out of proportion to weakness; a paralyzed limb cannot demonstrate ataxia and is scored 0.

Question 15: In the NIHSS standardized sentence reading card, one of the phrases is 'You know how.' What aspect of language does reading this sentence aloud primarily assess?

Auditory comprehension and repetition
Object naming from visual recognition
Reading aloud, combining visual decoding and verbal output (Correct answer)
Spontaneous narrative generation

Correct answer: Reading aloud, combining visual decoding and verbal output

Reading aloud tests grapheme-to-phoneme conversion plus motor speech output, helping identify alexia with or without dysfluency alongside aphasia.

Question 16: On NIHSS Item 1c (LOC Commands), the patient is asked to open and close their eyes and then grip and release their hand. The patient correctly performs only the first command. What is the score?

3
1 (Correct answer)
0
2

Correct answer: 1

Performing only one of the two commands correctly results in a score of 1 on Item 1c.

Question 17: When assessing limb ataxia in the NIHSS, what is being evaluated?

Sensory response
Reflexes
Muscle strength
Coordination and smoothness of movements (Correct answer)

Correct answer: Coordination and smoothness of movements

Limb ataxia assessment evaluates coordination and smoothness of movements to identify cerebellar dysfunction.

Question 18: For Item 10 (Dysarthria) in the Group A patient, the patient's speech is completely unintelligible even in short phrases. What is the correct score?

0 — normal
2 — severe dysarthria, nearly unintelligible or mute (Correct answer)
NT — intubated or has a physical barrier
1 — mild to moderate dysarthria

Correct answer: 2 — severe dysarthria, nearly unintelligible or mute

Severe dysarthria (score 2) applies when speech is so slurred it is nearly unintelligible or the patient is mute due to motor speech impairment.

Question 19: A patient demonstrates asymmetric eye closure: the left eye does not fully close during sleep or volitional effort, and the left lower face is completely flaccid. This pattern is most consistent with:

Central (UMN) facial palsy, NIHSS score 2
Normal variant, NIHSS score 0
Peripheral (LMN) facial palsy, NIHSS score 3 (Correct answer)
Partial central palsy, NIHSS score 1

Correct answer: Peripheral (LMN) facial palsy, NIHSS score 3

Inability to close the eye combined with lower facial flaccidity indicates peripheral (LMN) facial nerve palsy, scored 3 on NIHSS.

Question 20: When assessing language on the NIHSS, the examiner asks the patient to name items on a standard card. What does difficulty naming common objects indicate?

Anomia, suggesting language pathway disruption (Correct answer)
Neglect, suggesting right hemisphere stroke
Dysarthria, indicating motor speech problem
Agnosia, indicating perceptual failure only

Correct answer: Anomia, suggesting language pathway disruption

Anomia (word-finding difficulty) during naming tasks reflects disruption of language networks and contributes to an aphasia score on NIHSS Item 9.

Question 21: Why is it important to test each eye's visual fields from directly in front during NIHSS assessment rather than from the side?

To prevent the patient from turning their head and compensating
To avoid any examiners' fingers entering the blind spot
Because the NIHSS protocol only tests central vision
To ensure fixation is maintained and peripheral fields are tested symmetrically (Correct answer)

Correct answer: To ensure fixation is maintained and peripheral fields are tested symmetrically

Testing from in front while the patient fixates on the examiner's nose ensures symmetric evaluation of all four quadrants without head-turn compensation.

Question 22: The Group A patient's speech is slurred but intelligible, and they can be understood with difficulty. What is the Item 10 (Dysarthria) score?

2 — severe dysarthria
0 — normal articulation
NT — intubated
1 — mild to moderate dysarthria (Correct answer)

Correct answer: 1 — mild to moderate dysarthria

Slurred but intelligible speech that can be understood represents mild to moderate dysarthria, scored as 1.

Question 23: Which of the following deficits is assessed under the "Motor Arm" section of the NIHSS?

Facial droop
Leg movement and strength
Arm movement and strength (Correct answer)
Speech clarity

Correct answer: Arm movement and strength

The "Motor Arm" section evaluates the movement and strength of the arms.

Question 24: An examiner asks a hemiplegic patient to perform heel-to-shin testing on the paretic leg. The patient cannot lift the leg at all. What is the correct score?

1
0
UN — untestable (Correct answer)
2

Correct answer: UN — untestable

When weakness prevents performance of the task, the item is scored UN (untestable) and ataxia cannot be attributed.

Question 25: A patient correctly detects finger movement in the left visual field but misses it every time it is presented simultaneously with the right. Without simultaneous presentation, the left field is intact. What does this finding suggest?

Bilateral blindness
Left hemianopia
Right hemianopia
Left visual extinction/neglect (Correct answer)

Correct answer: Left visual extinction/neglect

Extinction only on simultaneous bilateral stimulation indicates visual neglect (extinction), not a true field cut.

Question 26: A patient has a cortical stroke and reports that the left arm feels 'numb and tingling' but pain is still perceived. How is this scored?

0 — pain is perceived so sensation is intact
2 — any numbness indicates severe loss
This symptom is not captured by NIHSS sensory testing
1 — partial sensory loss with preserved pain perception (Correct answer)

Correct answer: 1 — partial sensory loss with preserved pain perception

Perceived numbness with partially preserved pain sensation represents mild-to-moderate loss, scored as 1.

Question 27: A Group A patient cannot follow either command for Item 1c due to quadriplegia. According to NIHSS protocol, how should this be scored?

Score 2 — performs neither task (Correct answer)
Score 0 — physical inability is not counted
Score 1 — partial credit given
Score NT — not testable

Correct answer: Score 2 — performs neither task

When a patient cannot perform commands due to physical inability (not cognitive failure), the score still reflects the observed response — score 2 if neither task is performed.

Question 28: A stroke patient can only perceive hand motion centrally in both eyes and has no peripheral vision. What is the NIHSS item 3 score?

3 — bilateral blindness (Correct answer)
2 — complete hemianopia
1 — partial loss
0 — normal

Correct answer: 3 — bilateral blindness

Bilateral visual field loss resulting in near-total blindness is scored 3, the maximum for NIHSS item 3.

Question 29: Which artery, when occluded, classically causes Wernicke's aphasia by damaging the posterior superior temporal gyrus?

Left anterior cerebral artery
Left posterior cerebral artery
Anterior branch of the left MCA
Posterior branch of the left MCA (Correct answer)

Correct answer: Posterior branch of the left MCA

Wernicke's area (posterior superior temporal gyrus, Brodmann area 22) is supplied by the posterior division of the left middle cerebral artery.

Question 30: In National Institutes of Health Stroke Scale, why is limb ataxia knowledge important for professional certification?

It demonstrates competence and ensures practitioners meet established standards (Correct answer)
It has no practical relevance to daily work
It is only required for administrative purposes
It is important only for entry-level positions

Correct answer: It demonstrates competence and ensures practitioners meet established standards

Professional certification in specific knowledge areas demonstrates that practitioners have met established competency standards, ensuring quality of service and public protection.

NIH Stroke Scale (NIHSS) Certification

The NIH Stroke Scale (NIHSS) certification by the American Heart Association tests healthcare professionals' ability to accurately assess neurological deficits in stroke patients using the standardized 11-category, 15-item clinical scale. It is required for nurses, physicians, and allied health professionals in stroke care settings.

Questions

60 min

Time Limit

80%

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