NIH Stroke Scale (NIHSS) Certification — Questions and Answers

Question 1: In National Institutes of Health Stroke Scale, why is facial palsy knowledge important for professional certification?

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

Question 2: When assessing leg motor function (Item 6), at what angle is the leg held for testing in a supine patient?

90 degrees
60 degrees
30 degrees (Correct answer)
45 degrees

Correct answer: 30 degrees

The leg is held at 30° off the bed for 5 seconds during NIHSS Item 6 assessment.

Question 3: A nurse performs NIHSS and notes the arm drifts to the bed in 4 seconds. A physician retests and the arm holds for 6 seconds. Which score is correct for documentation?

The most recent examiner's finding is used (Correct answer)
The nurse's score (worse finding)
The physician's score (most recent)
Both scores should be averaged

Correct answer: The most recent examiner's finding is used

NIHSS scores reflect the most recent standardized assessment; serial exams replace prior scores for that time point.

Question 4: A patient with a prior right-sided Bell's palsy presents with a new left MCA stroke and shows left lower facial droop. How should the examiner approach NIHSS Facial Palsy scoring?

Score 0 because the examiner cannot attribute findings to the acute stroke
Mark both sides as untestable due to confounding prior history
Average the findings from both sides
Score only the new left-sided weakness; document the old right-sided palsy separately (Correct answer)

Correct answer: Score only the new left-sided weakness; document the old right-sided palsy separately

The NIHSS scores deficits attributable to the acute stroke; the prior Bell's palsy on the right is documented but does not affect scoring of new left-sided findings.

Question 5: A patient with acute stroke is intubated and sedated. The team needs an NIHSS Best Gaze score. Which approach is appropriate?

Skip the item — sedated patients cannot be scored on any NIHSS item
Mark the item as untestable (UN) and exclude it from total
Perform the oculocephalic maneuver to assess horizontal eye movement (Correct answer)
Assume a score of 0 since sedation causes no gaze deviation

Correct answer: Perform the oculocephalic maneuver to assess horizontal eye movement

In unconscious or sedated patients, the oculocephalic (doll's eye) maneuver is the accepted method for testing Best Gaze.

Question 6: In the context of NIHSS Item 11, what does 'inattention' refer to?

Reduced level of consciousness
Failure to attend to one side of space without a primary sensory loss (Correct answer)
Inability to follow verbal commands
Inability to sustain attention on any task

Correct answer: Failure to attend to one side of space without a primary sensory loss

Inattention in Item 11 means the patient neglects one hemi-space despite having intact basic sensory pathways when tested alone.

Question 7: What is a best practice in National Institutes of Health Stroke Scale extinction and inattention?

Any practice that is easy to implement
A practice used only by large organizations
A method or technique recognized as superior based on evidence and expert consensus (Correct answer)
The cheapest available approach

Correct answer: A method or technique recognized as superior based on evidence and expert consensus

Best practices are methods, techniques, or approaches that are recognized through evidence, research, and expert consensus as producing superior results and are recommended for adoption.

Question 8: What is a rubric used for in National Institutes of Health Stroke Scale assessment?

To calculate statistical averages
To record attendance data
To schedule assessment dates
To define criteria and performance levels for evaluating work quality (Correct answer)

Correct answer: To define criteria and performance levels for evaluating work quality

A rubric is a scoring guide that defines specific criteria and describes performance levels for each criterion, providing consistent and transparent evaluation standards.

Question 9: A comatose patient's leg immediately falls to the bed when placed at 30°. What NIHSS Item 6 score is recorded?

4
UN
3 (Correct answer)
2

Correct answer: 3

A score of 3 is given when there is no effort against gravity and the limb falls immediately.

Question 10: Which NIHSS item specifically tests whether the patient can correctly state their age and the current month?

Item 1c - LOC Commands
Item 1b - LOC Questions (Correct answer)
Item 1a - Level of Consciousness
Item 2 - Best Gaze

Correct answer: Item 1b - LOC Questions

Item 1b tests orientation by asking the patient their age and the current month.

Question 11: 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
1 — give partial credit for an attempt
UN — untestable due to speech impairment
Correct — if the intent is clearly the right answer despite dysarthria (Correct answer)

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 12: In National Institutes of Health Stroke Scale, what role does continuing education play in level of consciousness?

To prevent professionals from advancing in their careers
To keep professionals current with evolving standards, technologies, and best practices (Correct answer)
To replace initial certification requirements
To increase testing frequency for compliance purposes

Correct answer: To keep professionals current with evolving standards, technologies, and best practices

Continuing education ensures professionals stay current with new developments, evolving standards, and emerging best practices in their field, maintaining competence throughout their careers.

Question 13: Visual and sensory integration- Hold fingers in upper and lower quadrants-Ask pt which is wiggling (L,R,&Both)

Extinction/Inattention (Correct answer)
Wakefulness
motor Coordination
sensory

Correct answer: Extinction/Inattention

he task of holding fingers in upper and lower quadrants and asking the patient which is wiggling (left, right, or both) assesses sensory integration. T<br>his evaluation examines the patient's ability to perceive and differentiate sensory stimuli in different areas of their visual field. It does not primarily focus on extinction/inattention, wakefulness, or motor coordination, but rather on the sensory aspect of their neurological function.

Question 14: Global aphasia results from large infarcts typically involving which artery's territory?

Left anterior cerebral artery
Basilar artery perforators
Left middle cerebral artery (Correct answer)
Right posterior cerebral artery

Correct answer: Left middle cerebral artery

Large left MCA territory infarcts damage both Broca's and Wernicke's areas, causing global aphasia with severe expressive and receptive deficits.

Question 15: In a Group A patient scenario, the patient has a right homonymous hemianopia confirmed by finger counting in all quadrants. What is the Item 3 (Visual Fields) score?

3 — bilateral hemianopia
1 — partial hemianopia
0 — no visual loss
2 — complete hemianopia (Correct answer)

Correct answer: 2 — complete hemianopia

Complete hemianopia is scored as 2 when an entire half of the visual field is lost in both eyes on the same side.

Question 16: A patient naming objects on the NIHSS card calls a 'feather' a 'thing for writing' instead. This circumlocution indicates:

Dysarthria
Phonemic paraphasia
Anomia with preserved semantic knowledge (Correct answer)
Pure alexia

Correct answer: Anomia with preserved semantic knowledge

Circumlocution — describing a word's function rather than stating the word — reflects anomia while showing the patient retains the concept but cannot retrieve its name.

Question 17: A patient has complete right hemisensory loss from a thalamic stroke. After 24 hours, some sensation returns in the arm but the leg remains anesthetic. What is the updated sensory score?

2 — any remaining anesthetic area maintains score 2
1 — some recovery with residual partial loss in one region (Correct answer)
Score cannot change within 24 hours of stroke
0 — partial return means normal

Correct answer: 1 — some recovery with residual partial loss in one region

Partial sensory recovery with residual loss in one region represents mild-to-moderate hemisensory loss, scored 1.

Question 18: Which visual field defect would most likely score 2 on NIHSS item 3?

Bilateral peripheral constriction
Right superior quadrantanopia only
Left homonymous hemianopia (Correct answer)
Left superior quadrantanopia only

Correct answer: Left homonymous hemianopia

Complete hemianopia (loss of an entire hemifield) scores 2 on NIHSS item 3.

Question 19: Which stimulus is considered appropriate to use when testing LOC arousal (Item 1a) for a patient who does not respond to voice?

Noxious stimulus such as nail bed pressure (Correct answer)
Cold water in the ear canal
Loud noise near the patient's ear
Bright light directed at the eyes

Correct answer: Noxious stimulus such as nail bed pressure

Noxious stimuli such as nail bed pressure or sternal rub are appropriate for assessing arousal when the patient doesn't respond to voice.

Question 20: A posterior fossa (brainstem) stroke is more likely than a hemispheric stroke to cause gaze deviation in which direction?

No gaze deviation
Purely vertical
Away from the lesion side (contralateral) (Correct answer)
Toward the lesion side

Correct answer: Away from the lesion side (contralateral)

Pontine lesions injure horizontal gaze centers and often cause deviation away from the lesion (contralateral), opposite to supratentorial strokes.

Question 21: Which of the following patients would receive a score of 0 on NIHSS Item 1a?

A patient who opens eyes only to voice
A patient who only withdraws from pain
A patient who is alert and responsive throughout the examination (Correct answer)
A patient requiring sternal rub to respond

Correct answer: A patient who is alert and responsive throughout the examination

A score of 0 on Item 1a means the patient is fully alert and keenly responsive.

Question 22: NIHSS Item 1c requires the patient to perform two motor commands. If a patient has a hand amputation, the examiner should:

Substitute another one-step command for the hand grip (Correct answer)
Score 2 because the command cannot be completed
Skip Item 1c entirely and note the amputation
Score 1 since only one limb can be tested

Correct answer: Substitute another one-step command for the hand grip

If a physical limitation like amputation prevents the standard command, the examiner substitutes another appropriate one-step motor command.

Question 23: A nurse re-evaluates a stroke patient 6 hours after admission and notes the patient can raise both eyebrows but cannot move the left lower face at all. She scores Facial Palsy as 2. Is this correct?

No – complete lower facial paralysis with intact upper face should be scored 3
Yes – bilateral findings always score 2
No – any facial asymmetry that involves total lower-face paralysis is scored 1
Yes – total lower facial paralysis with spared upper face is score 2 (Correct answer)

Correct answer: Yes – total lower facial paralysis with spared upper face is score 2

Score 2 correctly captures total or near-total lower facial paresis with the upper face spared, which is the definition of partial (central) palsy.

Question 24: Which NIHSS item is scored differently for patients who are intubated versus non-intubated?

Item 7 (Limb Ataxia)
Item 1b (LOC Questions)
Item 9 (Dysarthria) (Correct answer)
Item 4 (Facial Palsy)

Correct answer: Item 9 (Dysarthria)

Item 9 has a specific notation (score 3 = UN) for intubated patients who cannot be tested for dysarthria.

Question 25: Which body regions should be tested during NIHSS sensory assessment?

Face and dominant hand only
Face, arm, trunk, and leg (Correct answer)
Arm and leg only
All four extremities and trunk, but not face

Correct answer: Face, arm, trunk, and leg

NIHSS sensory testing includes the face, arm, trunk, and leg to map the distribution of sensory loss.

Question 26: What does "language proficiency" mean in National Institutes of Health Stroke Scale?

Knowing the dictionary definition of every word
The ability to use language effectively for communication in various contexts (Correct answer)
Having native-level pronunciation only
Being able to recite grammar rules perfectly

Correct answer: The ability to use language effectively for communication in various contexts

Language proficiency encompasses the ability to understand and produce language effectively across different contexts, including reading, writing, speaking, and listening in academic, professional, and social settings.

Question 27: On NIHSS Item 9, an intubated patient cannot speak. How should the examiner handle language scoring?

Skip Item 9 entirely and mark as untestable
Score 3 automatically because the patient cannot communicate
Score 0 because the limitation is mechanical, not neurological
Use written responses; score based on written language ability (Correct answer)

Correct answer: Use written responses; score based on written language ability

NIHSS guidelines allow written responses for intubated patients to assess language, and scoring reflects the written language ability observed.

Question 28: A stroke patient scores 2 on the limb ataxia item. What does this indicate?

Ataxia present in one limb only
Ataxia present in two limbs (Correct answer)
Severe ataxia preventing any limb movement
Mild ataxia in one limb

Correct answer: Ataxia present in two limbs

A score of 2 on the NIHSS limb ataxia item means ataxia is present in two limbs.

Question 29: In National Institutes of Health Stroke Scale, what role does continuing education play in sensory testing?

To replace initial certification requirements
To prevent professionals from advancing in their careers
To keep professionals current with evolving standards, technologies, and best practices (Correct answer)
To increase testing frequency for compliance purposes

Correct answer: To keep professionals current with evolving standards, technologies, and best practices

Continuing education ensures professionals stay current with new developments, evolving standards, and emerging best practices in their field, maintaining competence throughout their careers.

Question 30: What is the maximum possible total score on the NIHSS?

40
45
42 (Correct answer)
38

Correct answer: 42

The NIHSS has a maximum total score of 42, achieved when all 15 items receive the highest possible scores.

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

35 min

Time Limit

80%

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