NIH Stroke Scale – All Test Groups A-F (Patients 1-6) Answer Key (2026) | Exams Nursing, Exams of Nursing

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NIH Stroke Scale – All Test Groups A-F (Patients 1-6)

Answer Key (2026) | Exams Nursing

1. What is the primary purpose of the NIH Stroke Scale (NIHSS)? A) To quantify the severity of neurological deficits in a stroke patient B) To diagnose the specific type of stroke C) To predict 30‑day mortality after a stroke D) To determine if a patient is eligible for tPA Correct Answer: To quantify the severity of neurological deficits in a stroke patient Rationale: The NIHSS is a systematic assessment tool that grades stroke‑related neurological impairment. It does not diagnose stroke type or directly determine tPA eligibility, although it informs acute treatment decisions. 2. Which item on the NIHSS specifically evaluates the patient’s level of consciousness? A) 2. Best Gaze B) 1a. Level of Consciousness (LOC) C) 1b. LOC Questions D) 9. Best Language Correct Answer: 1a. Level of Consciousness (LOC)

Rationale: Item 1b scores 2 when the patient fails to answer both age and month correctly. A score of 1 indicates one correct answer, and 0 indicates both correct.

1. Which statement about scoring item 1c (LOC Commands) is correct? A) 0 is given if the patient performs both tasks (e.g., opening and closing eyes, gripping and releasing hand) B) 1 is given only if the patient cannot follow any command C) 2 is given when the patient obeys one command D) 3 is used for patients who are intubated Correct Answer: 0 is given if the patient performs both tasks (e.g., opening and closing eyes, gripping and releasing hand) Rationale: Item 1c scores 0 for both commands performed correctly, 1 for one command, and 2 for neither. No 3 exists on this item.
2. A patient has forced eye deviation that cannot be overcome by the oculocephalic maneuver. What is the appropriate score for best gaze? A) 0 B) 2 C) 1 D) Unable to assess Correct Answer: 2

Rationale: Forced deviation that cannot be voluntarily or reflexively overcome scores 2. A score of 1 is given for partial gaze palsy or an abnormality correctable by oculocephalic maneuver.

1. Visual field testing on the NIHSS is recorded under which item number? A) 2 B) 4 C) 3 D) 5 Correct Answer: 3 Rationale: Item 3 assesses visual fields by confrontation, scoring 0 for no loss, 1 for partial hemianopia, 2 for complete hemianopia, and 3 for bilateral hemianopia.
2. What is the maximum possible score for facial palsy on the NIHSS? A) 1 B) 2 C) 3 D) 4 Correct Answer: 3

Rationale: The leg is elevated to 30 degrees in the supine patient. Drift is scored if the leg falls before 5 seconds; scores increase with more severe weakness.

1. Limb ataxia is scored as present in one limb when the examiner identifies which finding? A) Tremor only at rest B) Unilateral weakness that prevents testing C) Dysmetria or incoordination on finger‑to‑nose or heel‑to‑shin testing D) Loss of all sensation in the limb Correct Answer: Dysmetria or incoordination on finger‑to‑nose or heel‑to‑shin testing Rationale: Ataxia is scored 1 if present in one limb and 2 if present in two limbs. It is not scored for limbs that are too weak to test; in that case, the item is marked as untestable. 1 2. According to the NIHSS scoring rules, sensory testing uses which type of stimulus? A) Light touch only B) Vibration C) Temperature D) Pinprick Correct Answer: Pinprick

Rationale: Sensory function is assessed with a pinprick, comparing sensation proximally to distally on each side. Score ranges from 0 (normal) to 2 (severe loss).

1. A patient who has severe aphasia and is unable to produce any meaningful speech receives which score on the best language item? A) 3 B) 1 C) 2 D) 0 Correct Answer: 3 Rationale: Score 3 indicates global aphasia; the patient is mute or produces only incomprehensible sounds. Scores 1 and 2 indicate mild to moderate aphasia.
2. Dysarthria is defined on the NIHSS as: A) Slurred speech due to weakness or incoordination of the speech muscles B) Inability to understand spoken language C) Complete inability to speak D) A voice disorder caused by vocal cord paralysis Correct Answer: Slurred speech due to weakness or incoordination of the speech muscles

Rationale: Item 9 is scored 0 when the patient correctly names objects, describes a picture, and reads sentences without errors. The absence of aphasia is the key.

1. If a patient is comatose and does not respond to any stimulus, what score is given for item 1a? A) 2 B) 0 C) 3 D) 1 Correct Answer: 3 Rationale: A score of 3 is reserved for a patient who is unresponsive or only exhibits reflexive posturing in response to noxious stimuli. This is the most severe LOC rating.
2. For item 2 (Best Gaze), a score of 1 indicates which finding? A) Forced deviation not overcome B) Normal horizontal eye movements C) Partial gaze palsy that can be overcome by voluntary or oculocephalic maneuvers D) Complete conjugate gaze paralysis Correct Answer: Partial gaze palsy that can be overcome by voluntary or oculocephalic maneuvers

Rationale: A score of 1 reflects an abnormality in voluntary gaze that can still be overcome reflexively. Forced deviation that cannot be overcome scores 2.

1. In scoring visual fields, a right homonymous hemianopia that spares the macula would be scored as: A) 2 B) 1 C) 3 D) 0 Correct Answer: 1 Rationale: A partial hemianopia (including a quadrantanopia) scores 1. Complete hemianopia scores 2. Bilateral hemianopia scores 3.
2. Which of the following best describes the scoring of item 4 (Facial Palsy) when the patient has flattening of the nasolabial fold and slight asymmetry on smiling? A) 2 B) 1 C) 0 D) 3 Correct Answer: 1

Rationale: Drift before 5 seconds constitutes a score of 1. Score 2 occurs when the leg falls to the bed by 5 seconds but has some effort against gravity. Score 0 is no drift for the full 5 seconds.

1. Limb ataxia is not scored if the limb is profoundly weak. In that case, the item is recorded as: A) 0 (absent) B) 2 (present in two limbs) C) 9 (untestable) D) 1 (present in one limb) Correct Answer: 9 (untestable) Rationale: When a limb is too weak to perform the coordination tasks, the examiner marks the item as “Untestable” (9) rather than assigning an ataxia score. This prevents falsely attributing ataxia when strength is absent.
2. For sensory testing, a score of 2 (severe loss) means the patient: A) Has mild to moderate loss on one side B) Is aware of being touched but does not feel pinprick on the affected side C) Does not feel pinprick or is not aware of being touched on the face, arm, or leg on one side D) Has bilateral sensory loss only Correct Answer: Does not feel pinprick or is not aware of being touched on the face, arm, or leg on one side

Rationale: Severe loss (score 2) indicates a dense hemisensory deficit. The patient may not realize they are being touched on the affected side.

25. Best Language assessment includes the patient’s ability to perform all of the following tasks except: A) Name objects B) Read a list of sentences C) Describe a picture D) Follow written commands Correct Answer: Read a list of sentences Rationale: Language evaluation includes object naming, picture description, and reading sentences. It does not include following written commands as a separate scored task; that is part of the overall comprehension assessment, but the phrase “read a list of sentences” is part of the formal aphasia testing. Actually, the NIHSS does include reading sentences. So I need to adjust. Let's correct: The item does test reading sentences. So I'll change the question to avoid confusion. I'll replace it with: "Best Language does not routinely test which of the following: A) Repetition of phrases" (since repetition is not part of NIHSS). I'll set answer to "Repetition of phrases" as the correct one. I'll adjust accordingly:

1. The NIHSS item 9 (Best Language) evaluates all of the following except: A) Naming objects B) Describing a picture C) Repetition of phrases

D) Complete denial of the hemiparetic side Correct Answer: Visual or tactile extinction to double simultaneous stimulation in one modality Rationale: A score of 1 reflects partial neglect or extinction in one sensory modality (e.g., visual or tactile). Score 2 is for profound neglect or extinction in multiple modalities.

1. In Group A, Patient 1 had a motor arm left score of 3. This indicates: A) No drift B) Limb falls to the bed before 10 seconds C) No effort against gravity; arm falls immediately D) No movement at all Correct Answer: No effort against gravity; arm falls immediately Rationale: A score of 3 means the arm makes some effort against gravity but falls to the bed immediately. Score 4 is no movement, and 2 is some effort but falls before 10 seconds.
2. According to the Group B key points, a score of 1 on the Best Language item indicates: A) Global aphasia B) Mild aphasia with halting speech and naming errors C) Normal language

D) Severe aphasia Correct Answer: Mild aphasia with halting speech and naming errors Rationale: Score 1 is characterized by mild to moderate aphasia with some word‑finding difficulty or paraphasic errors. Score 2 is severe aphasia, and score 3 is global.

1. The Group C table shows Patient 3 had a Best Gaze score of 2. This means: A) Normal gaze B) Partial gaze palsy C) Forced deviation not overcome by oculocephalic maneuver D) The item was untestable Correct Answer: Forced deviation not overcome by oculocephalic maneuver Rationale: Score 2 on gaze indicates a forced conjugate deviation that cannot be corrected by voluntary or reflex maneuvers. This is a grave sign.
2. What score on the NIHSS item 3 (Visual) is given for a patient with a complete right homonymous hemianopia? A) 3 B) 2 C) 1 D) 0

Rationale: Item 5a tests left arm motor function, and 5b tests right arm motor function. Legs are tested under 6a (left) and 6b (right).

1. The maximum possible total score on the NIHSS is: A) 15 B) 25 C) 42 D) 30 Correct Answer: 42 Rationale: Summing the maximum scores from each item (3+2+2+2+3+3+4+4+4+4+2+2+3+2+2) yields a possible total of 42. A score of 0 is normal.
2. A patient with a total NIHSS score of 0 would be described as: A) Severe stroke B) Moderate stroke C) Mild stroke D) No stroke‑related neurological deficits Correct Answer: No stroke‑related neurological deficits Rationale: A score of 0 indicates that the examiner found no detectable deficits on any NIHSS item. This is consistent with no stroke or a very mild TIA without residual signs.

36. Which item on the NIHSS can be scored as “Untestable” if the patient is unable to cooperate due to coma? A) 1a (LOC) B) 9 (Best Language) C) 5a/5b (Motor Arm) D) All items can be attempted; none are scored untestable in coma Correct Answer: 5a/5b (Motor Arm) Rationale: In a comatose patient, motor items are still scored based on observed movement or lack thereof. However, some items like limb ataxia are marked untestable (9) if the limb is too weak. Actually, in coma, many items are testable. But the correct answer among these: item 5a/5b can be scored based on response to noxious stimuli. I'll clarify: The NIHSS explicitly allows scoring of motor items even in coma by using noxious stimulation; limb ataxia is untestable. So I'll adjust: question 36: "Which item is most likely scored as 'Untestable' in a comatose patient?" Answer: Limb ataxia (7). I'll set that as correct. I'll modify the question: "Which NIHSS item is routinely scored as 9 (Untestable) in a patient who is comatose and cannot perform coordinated movements?" Answer: 7. Limb Ataxia. I'll craft it. 36. Which NIHSS item is most likely scored as “Untestable” (9) in a comatose patient? A) 1a. LOC B) 9. Best Language C) 5a. Motor Arm Left D) 7. Limb Ataxia