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NIHSS Group A Version 5, Exams of Nursing

Walden UniversityNursing

NIHSS Group A Version 5 NIHSS Group A Version 5

Typology: Exams

2025/2026

Available from 06/23/2026

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NIHSS Group A Version 5
Part 1: Patient 1 - Complete Scoring and Rationales (Questions 1-15)
1. What is the correct 1a (Level of Consciousness) score for Patient 1?
• Answer: 0
• Rationale: Patient 1 is alert and keenly responsive, indicating
normal arousal. An alert patient receives 0, regardless of
orientation or confusion .
2. What is the correct 1b (LOC Questions) score for Patient 1?
• Answer: 0
• Rationale: The patient answers both orientation questions (month
and age) correctly. Two correct responses = score 0 .
3. What is the correct 1c (LOC Commands) score for Patient 1?
• Answer: 0
• Rationale: The patient performs both commands ("blink eyes" and
"squeeze hands") correctly. Performing both tasks = score 0 .
4. What is the correct Best Gaze score for Patient 1?
• Answer: 0
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NIHSS Group A Version 5

Part 1: Patient 1 - Complete Scoring and Rationales (Questions 1-15)

  1. What is the correct 1a (Level of Consciousness) score for Patient 1?
    • Answer: 0
    • Rationale: Patient 1 is alert and keenly responsive, indicating normal arousal. An alert patient receives 0, regardless of orientation or confusion.
  2. What is the correct 1b (LOC Questions) score for Patient 1?
    • Answer: 0
    • Rationale: The patient answers both orientation questions (month and age) correctly. Two correct responses = score 0.
  3. What is the correct 1c (LOC Commands) score for Patient 1?
    • Answer: 0
    • Rationale: The patient performs both commands ("blink eyes" and "squeeze hands") correctly. Performing both tasks = score 0.
  4. What is the correct Best Gaze score for Patient 1?
    • Answer: 0
  • Rationale: Patient demonstrates normal horizontal eye movements with no gaze deviation.
  1. What is the correct Visual Fields score for Patient 1?
  • Answer: 0
  • Rationale: No visual field deficit is present on examination.
  1. What is the correct Facial Palsy score for Patient 1?
  • Answer: 1
  • Rationale: Minor paralysis is present, demonstrated by flattened nasolabial fold and asymmetry on smiling. This is classified as mild to moderate weakness.
  1. What is the correct Motor Arm Left (5a) score for Patient 1?
  • Answer: 3
  • Rationale: The left arm falls immediately with no effort against gravity. No antigravity effort = score 3.
  1. What is the correct Motor Arm Right (5b) score for Patient 1?
  • Answer: 0
  • Rationale: The right arm holds at 90 degrees for the full 10 seconds without drift. Normal arm = score 0.
  1. What is the correct Motor Leg Left (6a) score for Patient 1?
  • Answer: 1
  • Rationale: The left leg drifts but does not hit the bed by the end of the 5-second period. Drift without full collapse = score 1.
  1. What is the correct Motor Leg Right (6b) score for Patient 1?

Part 2: Patient 2 - Complete Scoring and Rationales (Questions 16-30)

  1. What is the correct 1a (Level of Consciousness) score for Patient 2?
    • Answer: 0
    • Rationale: Alert and responsive; normal arousal.
  2. What is the correct 1b (LOC Questions) score for Patient 2?
    • Answer: 2
    • Rationale: Patient answers neither orientation question correctly (month and age). Two incorrect responses = score 2.
  3. What is the correct 1c (LOC Commands) score for Patient 2?
    • Answer: 0
    • Rationale: Performs both commands correctly. Score 0 indicates intact command-following.
  4. What is the correct Best Gaze score for Patient 2?
    • Answer: 0
    • Rationale: Normal horizontal eye movements without gaze deviation.
  5. What is the correct Visual Fields score for Patient 2?
    • Answer: 0
    • Rationale: No visual field deficit detected.
  6. What is the correct Facial Palsy score for Patient 2?
    • Answer: 1
  • Rationale: Minor paralysis with flattened nasolabial fold and asymmetry on smiling.
  1. What is the correct Motor Arm Left (5a) score for Patient 2?
  • Answer: 0
  • Rationale: Left arm holds at 90 degrees for 10 seconds without drift.
  1. What is the correct Motor Arm Right (5b) score for Patient 2?
  • Answer: 0
  • Rationale: Right arm holds at 90 degrees for 10 seconds without drift.
  1. What is the correct Motor Leg Left (6a) score for Patient 2?
  • Answer: 0
  • Rationale: Left leg holds at 30 degrees for 5 seconds without drift.
  1. What is the correct Motor Leg Right (6b) score for Patient 2?
  • Answer: 0
  • Rationale: Right leg holds at 30 degrees for 5 seconds without drift.
  1. What is the correct Limb Ataxia score for Patient 2?
  • Answer: 0
  • Rationale: No ataxia on finger-to-nose or heel-to-shin testing.
  1. What is the correct Sensory score for Patient 2?
  • Answer: 1
  • Rationale: Answers both orientation questions (month and age) correctly.
  1. What is the correct 1c (LOC Commands) score for Patient 3?
  • Answer: 0
  • Rationale: Performs both commands correctly.
  1. What is the correct Best Gaze score for Patient 3?
  • Answer: 0 or 1 (varies by source)
  • Rationale: Most sources show 0 ; some show partial gaze palsy (1). Normal gaze = 0; partial gaze palsy = 1.
  1. What is the correct Visual Fields score for Patient 3?
  • Answer: 0 or 1 (varies by source)
  • Rationale: Most sources show 0 ; some show 1. No visual loss = 0; partial hemianopia = 1.
  1. What is the correct Facial Palsy score for Patient 3?
  • Answer: 1 (or 0 in some sources)
  • Rationale: Minor paralysis with flattened nasolabial fold and asymmetry on smiling. Some sources show 0.
  1. What is the correct Motor Arm Left (5a) score for Patient 3?
  • Answer: 0 (or 1 in some sources)
  • Rationale: Left arm holds at 90 degrees without drift.
  1. What is the correct Motor Arm Right (5b) score for Patient 3?
  • Answer: 0 (or varies by source)
  • Rationale: Right arm holds at 90 degrees for 10 seconds without drift.
  1. What is the correct Motor Leg Left (6a) score for Patient 3?
  • Answer: 2
  • Rationale: Left leg drifts and hits the bed before 5 seconds. Drift with full collapse = score 2.
  1. What is the correct Motor Leg Right (6b) score for Patient 3?
  • Answer: 2
  • Rationale: Right leg drifts and hits the bed before 5 seconds. Drift with full collapse = score 2.
  1. What is the correct Limb Ataxia score for Patient 3?
  • Answer: 0 or 1 (varies by source)
  • Rationale: Most sources show 0 ; some show 1. No ataxia = 0; one limb with ataxia = 1.
  1. What is the correct Sensory score for Patient 3?
  • Answer: 1
  • Rationale: Mild to moderate sensory loss present.
  1. What is the correct Best Language score for Patient 3?
  • Answer: 0 or 1 (varies by source)
  • Rationale: Most sources show 0 ; some show 1. Normal language = 0; mild aphasia = 1.
  1. What is the correct Dysarthria score for Patient 3?
  • Answer: 0
  • Rationale: No visual field deficit detected.
  1. What is the correct Facial Palsy score for Patient 4?
  • Answer: 0 (or 1 in some sources)
  • Rationale: Most sources show normal facial movement. Some show minor paralysis.
  1. What is the correct Motor Arm Left (5a) score for Patient 4?
  • Answer: 0
  • Rationale: Left arm holds at 90 degrees without drift.
  1. What is the correct Motor Arm Right (5b) score for Patient 4?
  • Answer: 0
  • Rationale: Right arm holds at 90 degrees without drift.
  1. What is the correct Motor Leg Left (6a) score for Patient 4?
  • Answer: 0
  • Rationale: Left leg holds at 30 degrees without drift.
  1. What is the correct Motor Leg Right (6b) score for Patient 4?
  • Answer: 0 or 1 (varies by source)
  • Rationale: Most sources show 0 ; some show 1. Normal = 0; drift = 1.
  1. What is the correct Limb Ataxia score for Patient 4?
  • Answer: 0
  • Rationale: No ataxia on finger-to-nose testing.
  1. What is the correct Sensory score for Patient 4?
    • Answer: 1
    • Rationale: Mild to moderate sensory loss present.
  2. What is the correct Best Language score for Patient 4?
    • Answer: 0
    • Rationale: Normal language; no aphasia.
  3. What is the correct Dysarthria score for Patient 4?
    • Answer: 0
    • Rationale: Normal articulation; no slurred speech.
  4. What is the correct Extinction/Inattention score for Patient 4?
    • Answer: 0
    • Rationale: No extinction on double simultaneous stimulation. Part 5: Patient 5 - Complete Scoring and Rationales (Questions 61-75)
  5. What is the correct 1a (Level of Consciousness) score for Patient 5?
    • Answer: 0
    • Rationale: Alert and responsive; normal arousal.
  6. What is the correct 1b (LOC Questions) score for Patient 5?
    • Answer: 1
    • Rationale: Patient answers one of the two orientation questions (month or age) correctly. One correct = score 1.
  • Answer: 1
  • Rationale: Left leg drifts but does not hit the bed by the end of 5 seconds.
  1. What is the correct Motor Leg Right (6b) score for Patient 5?
  • Answer: 0
  • Rationale: Right leg holds at 30 degrees without drift.
  1. What is the correct Limb Ataxia score for Patient 5?
  • Answer: 1
  • Rationale: Ataxia present in one limb on finger-to-nose testing.
  1. What is the correct Sensory score for Patient 5?
  • Answer: 1
  • Rationale: Mild to moderate sensory loss.
  1. What is the correct Best Language score for Patient 5?
  • Answer: 0 or 1 (varies by source)
  • Rationale: Most sources show 0 ; some show 1. Normal language = 0; mild aphasia = 1.
  1. What is the correct Dysarthria score for Patient 5?
  • Answer: 0
  • Rationale: Normal articulation; no dysarthria.
  1. What is the correct Extinction/Inattention score for Patient 5?
  • Answer: 1
  • Rationale: Extinction to double simultaneous stimulation testing.

Part 6: Patient 6 - Complete Scoring and Rationales (Questions 76-90)

  1. What is the correct 1a (Level of Consciousness) score for Patient 6?
    • Answer: 0
    • Rationale: Alert and keenly responsive.
  2. What is the correct 1b (LOC Questions) score for Patient 6?
    • Answer: 0
    • Rationale: Answers both orientation questions correctly.
  3. What is the correct 1c (LOC Commands) score for Patient 6?
    • Answer: 0
    • Rationale: Performs both commands correctly.
  4. What is the correct Best Gaze score for Patient 6?
    • Answer: 0
    • Rationale: Normal horizontal eye movements.
  5. What is the correct Visual Fields score for Patient 6?
    • Answer: 0
    • Rationale: No visual field deficit.
  6. What is the correct Facial Palsy score for Patient 6?
    • Answer: 0
    • Rationale: Normal facial symmetry and movement.
  7. What is the correct Motor Arm Left (5a) score for Patient 6?
  1. What is the correct Dysarthria score for Patient 6?
    • Answer: 0
    • Rationale: Normal articulation; no dysarthria.
  2. What is the correct Extinction/Inattention score for Patient 6?
    • Answer: 0
    • Rationale: No extinction on double simultaneous stimulation. Part 7: General NIHSS Questions with Rationales (Questions 91-100)
  3. What is the primary purpose of the NIH Stroke Scale?
    • Answer: Quantify stroke severity
    • Rationale: The NIHSS measures stroke severity, not diagnosis. Scores range from 0 (normal) to 42 (severe stroke). The total score predicts functional outcome.
  4. How is Sensory (Item 8) assessed in the NIHSS?
    • Answer: Using pinprick testing
    • Rationale: Pinprick testing is required for sensory assessment. Score 0 = normal, 1 = mild to moderate loss, 2 = severe or total loss.
  5. How are 1b (LOC Questions) and 1c (LOC Commands) scored?
    • Answer: 1b scores 0-2 based on correct answers; 1c scores 0- 2 based on command performance
  • Rationale: 1b: both correct = 0, one correct = 1, neither correct =
    1. 1c: both performed = 0, one performed = 1, neither performed = 2.
  1. How is Limb Ataxia (Item 7) scored?
  • Answer: 0 for none, 1 for one limb, 2 for two limbs
  • Rationale: Limb ataxia is scored only if weakness is absent or minimal. One limb with ataxia = 1; two limbs = 2. Ataxia cannot be judged when weakness interferes.
  1. What is the scoring range for Motor Arm (Item 5)?
  • Answer: 0 - 4 per arm
  • Rationale: Arm is held at 90 degrees (sitting) or 45 degrees (supine) for 10 seconds. 0 = no drift; 1 = drift; 2 = drift to bed; 3 = no antigravity effort; 4 = no movement.
  1. What is the scoring range for Motor Leg (Item 6)?
  • Answer: 0 - 4 per leg
  • Rationale: Leg is raised 30 degrees for 5 seconds. 0 = no drift; 1 = drift; 2 = drift to bed; 3 = no antigravity effort; 4 = no movement.
  1. How is Extinction/Inattention (Item 11) tested and scored?
  • Answer: Double simultaneous stimulation; score 0- 2
  • Rationale: Extinction is tested with double simultaneous stimulation. 0 = no extinction; 1 = extinction to one modality; 2 = profound hemi-inattention.
  1. What is the total score range for the NIHSS?