NIHSS Level of Consciousness 5 — Questions and Answers
Question 1: A patient with severe dysarthria attempts to answer orientation questions but speech is completely unintelligible. NIHSS Item 1b should be scored as:
- 0 - effort is recognized
- 1 - partial credit for attempting
- 2 - unable to provide scoreable verbal response (Correct answer)
- Deferred, pending speech therapy evaluation
Correct answer: 2 - unable to provide scoreable verbal response
If the patient cannot produce intelligible answers due to dysarthria, both questions are considered unanswered, scoring a 2 on Item 1b.
Question 2: 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
- No, all three LOC items must be completed and documented for every assessment (Correct answer)
- Yes, all LOC items can be skipped for alert patients to save time
- Only Item 1c can be skipped for alert patients
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 3: Which stimulus is considered appropriate to use when testing LOC arousal (Item 1a) for a patient who does not respond to voice?
- Bright light directed at the eyes
- Noxious stimulus such as nail bed pressure (Correct answer)
- Loud noise near the patient's ear
- Cold water in the ear canal
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 4: A patient who is post-ictal after a seizure opens eyes to voice but is confused about the month. For Item 1a they score 1, and for Item 1b they score 1. What is the combined LOC sub-score for items 1a and 1b?
- 0
- 1
- 2 (Correct answer)
- 3
Correct answer: 2
1a=1 plus 1b=1 equals a combined LOC sub-score of 2 for those two items.
Question 5: NIHSS Item 1c requires the patient to perform two motor commands. If a patient has a hand amputation, the examiner should:
- Score 2 because the command cannot be completed
- Substitute another one-step command for the hand grip (Correct answer)
- 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 6: In a hospital monitoring a stroke patient every 4 hours, which finding on repeat NIHSS LOC assessment should prompt immediate physician notification?
- Item 1a remains stable at 0
- Item 1b improves from 2 to 1
- Item 1a worsens from 1 to 3 (Correct answer)
- Item 1c improves from 1 to 0
Correct answer: Item 1a worsens from 1 to 3
Worsening Item 1a from 1 to 3 indicates rapid neurological deterioration and requires immediate physician notification.
Question 7: Which of the following best explains why the NIHSS LOC section uses three separate scored items (1a, 1b, 1c) rather than a single composite score?
- To increase the total possible NIHSS score artificially
- To distinguish between impaired arousal, orientation, and command-following as separate neurological functions (Correct answer)
- Because federal regulations mandate three sub-scores
- To allow partial completion of the LOC section in busy emergency departments
Correct answer: To distinguish between impaired arousal, orientation, and command-following as separate neurological functions
The three sub-items capture distinct neurological functions: wakefulness, orientation, and motor command-following, which can be independently affected by stroke.
NIHSS Level of Consciousness 5
A patient with severe dysarthria attempts to answer orientation questions but speech is completely unintelligible.
NIHSS Item 1b should be scored as: