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APEX NIH STROKE SCALE GROUP A PATIENTS
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Course: Clinical Neurology & Emergency Stroke Assessment
Subject: NIH Stroke Scale (NIHSS) Competency Evaluation
Description
This exam evaluates mastery of the National Institutes of Health Stroke Scale (NIHSS) using APEX-style Group A patient vignettes (Patients 1–6). Questions emphasize scoring accuracy, pathophysiologic understanding, correct interpretation of patient responses, assessment sequence, and clinical decision- making. Candidates must demonstrate detailed proficiency in evaluating level of consciousness, gaze, visual fields, facial palsy, motor strength, limb ataxia, sensory deficits, language, dysarthria, and extinction/inattention. The test reflects real- world stroke scenarios requiring precision, clinical reasoning, and consistent scoring methodology.
- When scoring LOC (1a) for a patient who is awake but disoriented, what score is appropriate?
A. 0 B. 1 C. 2 D. 3 Answer: A Rationale: LOC (1a) scores arousal, not orientation. As long as the patient is awake and responsive, the score is 0.
- A patient in Group A Patient 1 opens eyes only to painful stimulation. What is the LOC (1a) score?
A. 0 B. 1 C. 2 D. 3 Answer: C Rationale: Eye opening to pain corresponds to “not alert; requires repeated stimulation,” scoring 2.
- When assessing LOC Questions (1b), what determines scoring?
A. Whether the patient attempts to answer B. Accuracy of answers C. Level of consciousness D. Motor ability to speak Answer: B Rationale: The score reflects correct vs. incorrect answers to age and month.
- A patient responds “I don’t know” to both LOC questions. Score?
A. 0 B. 1 C. 2 D. 3 Answer: C Rationale: Two incorrect responses = score 2.
- Group A Patient 2 attempts to follow commands but performs the wrong movement. What is the correct score for LOC Commands (1c)?
A. 0 B. 1 C. 2
- Group A Patient 3 shows right gaze preference that resolves with oculocephalic testing. Score?
A. 0 B. 1 C. 2 D. 3 Answer: B Rationale: Overcome deviation = partial palsy → 1.
- Best Visual (3): Patient is unable to see fingers on the left but sees all on the right. Score?
A. 0 B. 1 C. 2 D. 3 Answer: B Rationale: Partial hemianopia scores 1.
- A patient shows complete left homonymous hemianopia. Score?
A. 0 B. 1 C. 2 D. 3 Answer: C Rationale: Complete hemianopia = 2.
- No visual response to any stimuli in both eyes. Score?
A. 0 B. 1 C. 2 D. 3
Answer: D Rationale: Bilateral blindness or cortical blindness scores 3.
- Facial palsy (4): You note only a flattened nasolabial fold on the right when smiling. Score?
A. 0 B. 1 C. 2 D. 3 Answer: B Rationale: Minor paralysis (mild asymmetry) = 1.
- Patient cannot close left eye tightly and has severe lower facial droop. Score?
A. 1 B. 2 C. 3 D. 4 Answer: C Rationale: Near complete paralysis of one side = score 3.
- No facial movement bilaterally despite stimulation. Score?
A. 0 B. 1 C. 2 D. 3 Answer: C Rationale: Bilateral paralysis counts as 3.
- When assessing motor arm (5), how long must the limb be held up?
- Motor leg: leg drifts but does not hit bed by 5 seconds. Score?
A. 0 B. 1 C. 2 D. 3 Answer: B Rationale: Drift without full collapse = 1.
- Patient cannot lift leg but shows some movement in-plane. Score?
A. 1 B. 2 C. 3 D. 4 Answer: C Rationale: No lift = 3.
- Limb ataxia is scored only if which condition is met?
A. Patient is aphasic B. Patient has weakness C. Weakness is absent or minimal D. Patient is unconscious Answer: C Rationale: Ataxia can only be judged when strength is adequate.
- Ataxia in one limb = what score?
A. 1 B. 2 C. 3 D. UN Answer: A Rationale: One limb = 1.
- Sensory: patient reports decreased pinprick on left side only. Score?
A. 0 B. 1 C. 2 D. 3 Answer: B Rationale: Mild sensory loss = 1.
- Patient shows complete loss of sensation on entire left side. Score?
A. 1 B. 2 C. 3 D. 4 Answer: C Rationale: Severe or total loss = 2.
- Best language (aphasia): Patient can name only one of the objects. Score?
A. 0 B. 1 C. 2 D. 3 Answer: B Rationale: Mild aphasia = 1.
- Patient produces incomprehensible sounds only. Score?
A. 2 B. 3 C. 4 D. UN
A. 1
B. 2
C. 3
D. UN
Answer: C Rationale: Severe neglect = 2.
- Group A Patient 4 shows left inattention but follows commands. Which scale element is affected?
A. 1a B. 4 C. 11 D. 3 Answer: C Rationale: Extinction/inattention relates to component 11.
- When scoring aphasia, which assessment material is used?
A. Hand squeeze B. Naming, reading, picture description C. Pupillary exam D. Visual fields Answer: B Rationale: NIHSS uses formal language tasks.
- Patient reads words but cannot form sentences. This indicates:
A. Normal B. Mild aphasia C. Moderate aphasia D. Severe aphasia Answer: C Rationale: Sentence formation difficulty reflects moderate aphasia.
- If patient is intubated, dysarthria is scored as:
A. 0 B. 1 C. 2 D. UN Answer: D Rationale: Intubation prevents reliable scoring → UN.
- Patient has complete left arm paralysis but normal right arm. What is motor arm total?
A. 3 B. 4 C. 5 D. 6 Answer: B Rationale: One arm score 4, the other 0 → total 4.
- For motor leg, inability to hold leg up but slight movement = what score?
A. 1 B. 2 C. 3 D. 4 Answer: C Rationale: No effort against gravity but movement in-plane = 3.
- Patient is blind in both eyes since childhood. How is visual field scored?
A. 0 B. 1 C. 2
A. Diagnose stroke B. Quantify stroke severity C. Select imaging modality D. Determine BP management Answer: B Rationale: NIHSS measures severity, not diagnosis.
- Patient with severe neglect appears unaware of paralysis. Which finding is typical?
A. Anosognosia B. Ptosis C. Diplopia D. Ataxia Answer: A Rationale: Anosognosia is unawareness of deficits.
- Which assessment is allowed for gaze scoring?
A. Vertical tracking B. Oculocephalic maneuver C. Caloric testing D. MRI review Answer: B Rationale: Oculocephalic reflex can clarify gaze palsy.
- Patient attempts to speak but produces meaningless jargon. This is:
A. Dysarthria B. Broca aphasia C. Wernicke aphasia D. Apraxia Answer: C Rationale: Fluent but nonsensical speech = Wernicke.
- A patient lifts arm but drifts to bed within 10 seconds. Score?
A. 0 B. 1 C. 2 D. 3 Answer: B Rationale: Drift without hitting bed = 1.
- Sensory: patient winces on one side but not the other. Score?
A. 0 B. 1 C. 2 D. 3 Answer: B Rationale: Reduced sensation = mild loss.
- Patient refuses to cooperate with instructions due to confusion. How score language?
A. 0 B. 1 C. 2 D. Use best estimate Answer: D Rationale: Examiner uses best clinical judgment based on available speech output.
- Patient has severe aphasia and cannot read words. Score?
A. 1 B. 2 C. 3
- While testing visual fields, patient gives inconsistent responses due to inattention. Appropriate action?
A. Score as missing B. Use best estimate C. Repeat until correct D. Skip the item Answer: B Rationale: NIHSS allows best clinical judgment when responses are inconsistent.
- A patient has newly developed complete right homonymous hemianopia. Score?
A. 1 B. 2 C. 3 D. UN Answer: C Rationale: Complete hemianopia = 2; full blindness = 3.
- Flattened left nasolabial fold with asymmetric smile but full eye closure suggests which facial score?
A. 0 B. 1 C. 2 D. 3 Answer: B Rationale: Minor paresis = 1.
- Patient shows no movement of right arm but normal left arm. What is total (5a
A. 3
B. 4
C. 5
D. 6
Answer: B Rationale: Paralyzed limb = 4; normal = 0; total = 4.
- During arm testing, patient falls asleep and cannot stay awake. What should the examiner do?
A. Use noxious stimulation B. Stop exam C. Wait for family D. Assume normal Answer: A Rationale: Noxious stimulation is allowed for motor scoring.
- Leg remains in the air but drifts 2 inches by 5 seconds. Score?
A. 0 B. 1 C. 2 D. 3 Answer: B Rationale: Drift without touching bed = 1.
- Ataxia is tested using which method?
A. Finger-to-nose, heel-to-shin B. Naming objects C. Pupillary light reflex D. Squeeze strength Answer: A Rationale: Standard cerebellar tests evaluate ataxia.
D. Arm drift Answer: B Rationale: Picture description assesses fluency and syntax.
- A patient produces only single words with effort. This indicates:
A. Mild aphasia B. Moderate aphasia C. Severe aphasia D. Dysarthria Answer: C Rationale: Limited verbal output = severe/global aphasia.
- Patient can repeat phrases but struggles to name objects. This pattern is typical of:
A. Wernicke aphasia B. Broca aphasia C. Global aphasia D. Pure dysarthria Answer: B Rationale: Broca aphasia impairs naming but preserves comprehension.
- Speech is slurred due to facial weakness but language intact. Score dysarthria:
A. 0 B. 1 C. 2 D. UN Answer: B Rationale: Mild distortion = 1.
- During extinction testing, patient perceives right stimulus but not simultaneous left. Score?
A. 0 B. 1 C. 2 D. 3 Answer: B Rationale: Mild neglect = 1.
- Both tactile and visual extinction noted. Score?
A. 1 B. 2 C. 3 D. UN Answer: B Rationale: Severe neglect = 2.
- Group A Patient 2 shows spontaneous movement in both legs but cannot lift them. Leg motor score?
A. 2 B. 3 C. 4 D. 5 Answer: B Rationale: No lift but some effort = 3.
- Patient unable to respond verbally but follows all commands. Best language score?
A. 0 B. 1 C. 2
