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

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

A patient answers 'November' when it is July, then correctly states their age. How is item 1b (LOC Questions) scored?

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.

For NIHSS item 1c (LOC Commands), which two commands must the examiner give?

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.

A patient with bilateral hand weakness cannot perform the hand grip command for item 1c. The examiner may:

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.

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:

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.

On item 1c (LOC Commands), can the examiner pantomime or demonstrate the command if the patient does not respond to verbal instruction alone?

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.