NIH Stroke Scale ACTUAL EXAM 2026 | Complete Set Groups
A-F | Patients 1-6 | Updated Clinical Training | Scoring
Guidance | Pass Guaranteed - A+ Graded
GROUP A: Right Hemisphere Strokes
Group A - Patient 1: Mild Right Hemisphere Stroke (Left Facial Weakness, Left Arm Drift,
Mild Neglect, No Visual Field Cut)
Group A - Patient 1 - Item 1a: Level of Consciousness (LOC):
Patient is awake, alert, and responsive to questions and commands without any stimulation.
Follows all instructions appropriately.
A. 1 - Not alert but arousable by minor stimulation
B. 2 - Not alert, requires repeated stimulation to attend
C. 0 - Alert, keenly responsive [CORRECT]
D. 3 - Unresponsive or responds only with reflex motor effects
Correct Answer: C
Rationale: Patient is awake and responsive without stimulation, meeting definition of 0 (alert,
keenly responsive) per NINDS 2026 guidelines. Score 1 requires drowsy/arousable, score 2
requires obtunded/repeated stimulation, score 3 requires coma. No effort against gravity is a
motor score, not LOC.
Group A - Patient 1 - Item 1b: LOC Questions (Month and Age):
Patient is alert and oriented. When asked "What month is it?" patient correctly responds "April."
When asked "How old are you?" patient correctly responds "72."
A. 2 - Answers neither correctly
B. 1 - Answers one correctly
C. 0 - Answers both correctly [CORRECT]
D. NT - Not testable (intubated/aphasic)
Correct Answer: C
Rationale: Patient answered both month and age correctly, scoring 0 per NINDS NIHSS training
manual. Score 1 if only one correct, score 2 if neither correct, NT only for intubation or severe
aphasia.
,Group A - Patient 1 - Item 2: Best Gaze (Horizontal Eye Movement):
Patient has conjugate horizontal eye movement. Eyes move fully to left and right without
deviation. No gaze preference or partial gaze palsy noted.
A. 2 - Forced deviation
B. 1 - Partial gaze palsy
C. 0 - Normal [CORRECT]
D. NT - Not testable
Correct Answer: C
Rationale: Patient has full conjugate eye movements without gaze deviation or palsy, scoring 0
per 2026 NIHSS certification standards. Score 1 for partial gaze palsy, score 2 for forced
deviation.
Group A - Patient 1 - Item 3: Visual Fields (Confrontation Testing):
On confrontation testing, patient sees fingers in all four quadrants bilaterally. No visual field cut
detected.
A. 3 - Bilateral hemianopia
B. 1 - Partial hemianopia (quadrantanopia)
C. 2 - Complete hemianopia
D. 0 - No visual loss [CORRECT]
Correct Answer: D
Rationale: Patient has intact visual fields in all quadrants, scoring 0 per NINDS guidelines.
Score 1 for quadrantanopia, score 2 for complete hemianopia, score 3 for bilateral blindness.
Group A - Patient 1 - Item 4: Facial Palsy:
Patient has mild asymmetry of lower face. When asked to show teeth, left side of mouth moves
but not fully. Left nasolabial fold flattened. Upper face symmetric.
A. 3 - Complete paralysis (upper and lower face)
B. 2 - Partial paralysis (lower face)
C. 0 - Normal symmetric movement
D. 1 - Minor paralysis (flattened nasolabial fold, asymmetric smile) [CORRECT]
Correct Answer: D
Rationale: Patient has minor lower face weakness with flattened nasolabial fold but movement
present, scoring 1 per NIHSS training materials. Score 0 for normal, score 2 for partial
(near-total lower face paralysis), score 3 for complete upper and lower.
Group A - Patient 1 - Item 5: Motor Arm (Worst Side - Left):
Patient extends left arm 90 degrees (sitting position). Arm maintains position for 8 seconds then
begins to drift downward but does not hit bed or other support within 10 seconds.
A. 4 - No movement (flaccid)
,B. 2 - Some effort against gravity
C. 3 - No effort against gravity (arm falls)
D. 1 - Drift (arm drifts down but does not hit bed) [CORRECT]
Correct Answer: D
Rationale: Patient maintains arm for 8 seconds then drifts downward without hitting support,
scoring 1 (drift) per NINDS 2026 scoring rules. Score 0 for no drift at 10 seconds, score 2 for
some effort against gravity before falling, score 3 for no effort against gravity, score 4 for no
movement.
Group A - Patient 1 - Item 6: Motor Leg (Worst Side - Left):
Patient is supine. Left leg is raised 30 degrees. Leg maintains position for full 5 seconds without
any downward drift.
A. 4 - No movement (flaccid)
B. 2 - Some effort against gravity
C. 0 - No drift [CORRECT]
D. 1 - Drift (leg drifts down but does not hit bed)
Correct Answer: C
Rationale: Patient maintains leg position for full 5 seconds without drift, scoring 0 per NIHSS
certification guidelines. Score 1 for drift before 5 seconds, score 2 for some effort against
gravity, score 3 for leg falls immediately, score 4 for no movement.
Group A - Patient 1 - Item 8: Sensory (Pinprick Testing):
Pinprick testing to face, arm, trunk, and leg. Patient has normal sensation on both sides.
Reports pinprick as equally sharp bilaterally.
A. 2 - Severe sensory loss (unaware of touch/pinprick)
B. 1 - Mild-to-moderate sensory loss (feels pinprick less sharp)
C. 0 - Normal (no sensory loss) [CORRECT]
D. NT - Not testable
Correct Answer: C
Rationale: Patient has normal sensation bilaterally, scoring 0 per NINDS training manual. Score
1 for patient acknowledging pinprick as less sharp or dull, score 2 for patient unaware of being
touched.
Group A - Patient 1 - Item 9: Best Language (Describe Picture, Name Items, Read Sentences):
Patient is able to describe the cookie theft picture fluently without word-finding difficulty. Names
items correctly. Reads sentences without error. Speech is fluent and comprehensible.
A. 3 - Mute, global aphasia
B. 2 - Severe aphasia (fragmented communication)
, C. 1 - Mild-to-moderate aphasia (some difficulty)
D. 0 - No aphasia [CORRECT]
Correct Answer: D
Rationale: Patient has no language deficit, fluent speech, normal naming and comprehension,
scoring 0 per 2026 NIHSS clinical training materials. Score 1 for mild loss of fluency or
comprehension, score 2 for severe fragmentation, score 3 for mute/global aphasia.
Group A - Patient 1 - Item 11: Extinction/Inattention (Double Simultaneous Stimulation):
On double simultaneous stimulation, patient perceives visual, tactile, and auditory stimuli on
both sides when stimulated simultaneously. No extinction or neglect noted.
A. 1 - Neglect in one modality
B. 0 - No neglect [CORRECT]
C. 2 - Profound neglect (more than one modality)
D. NT - Not testable
Correct Answer: B
Rationale: Patient has no neglect or extinction in any modality, scoring 0 per NINDS guidelines.
Score 1 for neglect in one modality (e.g., tactile extinction), score 2 for profound neglect in more
than one modality.
Group A - Patient 2: Moderate Right Hemisphere Stroke (Left Hemiplegia, Left Hemianopia, Left
Neglect, Mild Dysarthria)
Group A - Patient 2 - Item 1a: Level of Consciousness (LOC):
Patient is awake and alert, responding immediately to the examiner's questions without any
need for repetitive or painful stimulation.
A. 2 - Not alert, requires repeated stimulation to attend
B. 3 - Unresponsive or responds only with reflex motor effects
C. 0 - Alert, keenly responsive [CORRECT]
D. 1 - Not alert but arousable by minor stimulation
Correct Answer: C
Rationale: Patient is fully awake and keenly responsive, scoring 0 per NIHSS 2026 certification
standards. Score 1 is for drowsiness requiring verbal stimulation, score 2 for obtundation
requiring tactile stimulation, score 3 for coma.
Group A - Patient 2 - Item 1b: LOC Questions (Month and Age):
Patient is alert. When asked "What month is it?" patient responds "March" (correct). When
asked "How old are you?" patient responds "68" (correct).
A-F | Patients 1-6 | Updated Clinical Training | Scoring
Guidance | Pass Guaranteed - A+ Graded
GROUP A: Right Hemisphere Strokes
Group A - Patient 1: Mild Right Hemisphere Stroke (Left Facial Weakness, Left Arm Drift,
Mild Neglect, No Visual Field Cut)
Group A - Patient 1 - Item 1a: Level of Consciousness (LOC):
Patient is awake, alert, and responsive to questions and commands without any stimulation.
Follows all instructions appropriately.
A. 1 - Not alert but arousable by minor stimulation
B. 2 - Not alert, requires repeated stimulation to attend
C. 0 - Alert, keenly responsive [CORRECT]
D. 3 - Unresponsive or responds only with reflex motor effects
Correct Answer: C
Rationale: Patient is awake and responsive without stimulation, meeting definition of 0 (alert,
keenly responsive) per NINDS 2026 guidelines. Score 1 requires drowsy/arousable, score 2
requires obtunded/repeated stimulation, score 3 requires coma. No effort against gravity is a
motor score, not LOC.
Group A - Patient 1 - Item 1b: LOC Questions (Month and Age):
Patient is alert and oriented. When asked "What month is it?" patient correctly responds "April."
When asked "How old are you?" patient correctly responds "72."
A. 2 - Answers neither correctly
B. 1 - Answers one correctly
C. 0 - Answers both correctly [CORRECT]
D. NT - Not testable (intubated/aphasic)
Correct Answer: C
Rationale: Patient answered both month and age correctly, scoring 0 per NINDS NIHSS training
manual. Score 1 if only one correct, score 2 if neither correct, NT only for intubation or severe
aphasia.
,Group A - Patient 1 - Item 2: Best Gaze (Horizontal Eye Movement):
Patient has conjugate horizontal eye movement. Eyes move fully to left and right without
deviation. No gaze preference or partial gaze palsy noted.
A. 2 - Forced deviation
B. 1 - Partial gaze palsy
C. 0 - Normal [CORRECT]
D. NT - Not testable
Correct Answer: C
Rationale: Patient has full conjugate eye movements without gaze deviation or palsy, scoring 0
per 2026 NIHSS certification standards. Score 1 for partial gaze palsy, score 2 for forced
deviation.
Group A - Patient 1 - Item 3: Visual Fields (Confrontation Testing):
On confrontation testing, patient sees fingers in all four quadrants bilaterally. No visual field cut
detected.
A. 3 - Bilateral hemianopia
B. 1 - Partial hemianopia (quadrantanopia)
C. 2 - Complete hemianopia
D. 0 - No visual loss [CORRECT]
Correct Answer: D
Rationale: Patient has intact visual fields in all quadrants, scoring 0 per NINDS guidelines.
Score 1 for quadrantanopia, score 2 for complete hemianopia, score 3 for bilateral blindness.
Group A - Patient 1 - Item 4: Facial Palsy:
Patient has mild asymmetry of lower face. When asked to show teeth, left side of mouth moves
but not fully. Left nasolabial fold flattened. Upper face symmetric.
A. 3 - Complete paralysis (upper and lower face)
B. 2 - Partial paralysis (lower face)
C. 0 - Normal symmetric movement
D. 1 - Minor paralysis (flattened nasolabial fold, asymmetric smile) [CORRECT]
Correct Answer: D
Rationale: Patient has minor lower face weakness with flattened nasolabial fold but movement
present, scoring 1 per NIHSS training materials. Score 0 for normal, score 2 for partial
(near-total lower face paralysis), score 3 for complete upper and lower.
Group A - Patient 1 - Item 5: Motor Arm (Worst Side - Left):
Patient extends left arm 90 degrees (sitting position). Arm maintains position for 8 seconds then
begins to drift downward but does not hit bed or other support within 10 seconds.
A. 4 - No movement (flaccid)
,B. 2 - Some effort against gravity
C. 3 - No effort against gravity (arm falls)
D. 1 - Drift (arm drifts down but does not hit bed) [CORRECT]
Correct Answer: D
Rationale: Patient maintains arm for 8 seconds then drifts downward without hitting support,
scoring 1 (drift) per NINDS 2026 scoring rules. Score 0 for no drift at 10 seconds, score 2 for
some effort against gravity before falling, score 3 for no effort against gravity, score 4 for no
movement.
Group A - Patient 1 - Item 6: Motor Leg (Worst Side - Left):
Patient is supine. Left leg is raised 30 degrees. Leg maintains position for full 5 seconds without
any downward drift.
A. 4 - No movement (flaccid)
B. 2 - Some effort against gravity
C. 0 - No drift [CORRECT]
D. 1 - Drift (leg drifts down but does not hit bed)
Correct Answer: C
Rationale: Patient maintains leg position for full 5 seconds without drift, scoring 0 per NIHSS
certification guidelines. Score 1 for drift before 5 seconds, score 2 for some effort against
gravity, score 3 for leg falls immediately, score 4 for no movement.
Group A - Patient 1 - Item 8: Sensory (Pinprick Testing):
Pinprick testing to face, arm, trunk, and leg. Patient has normal sensation on both sides.
Reports pinprick as equally sharp bilaterally.
A. 2 - Severe sensory loss (unaware of touch/pinprick)
B. 1 - Mild-to-moderate sensory loss (feels pinprick less sharp)
C. 0 - Normal (no sensory loss) [CORRECT]
D. NT - Not testable
Correct Answer: C
Rationale: Patient has normal sensation bilaterally, scoring 0 per NINDS training manual. Score
1 for patient acknowledging pinprick as less sharp or dull, score 2 for patient unaware of being
touched.
Group A - Patient 1 - Item 9: Best Language (Describe Picture, Name Items, Read Sentences):
Patient is able to describe the cookie theft picture fluently without word-finding difficulty. Names
items correctly. Reads sentences without error. Speech is fluent and comprehensible.
A. 3 - Mute, global aphasia
B. 2 - Severe aphasia (fragmented communication)
, C. 1 - Mild-to-moderate aphasia (some difficulty)
D. 0 - No aphasia [CORRECT]
Correct Answer: D
Rationale: Patient has no language deficit, fluent speech, normal naming and comprehension,
scoring 0 per 2026 NIHSS clinical training materials. Score 1 for mild loss of fluency or
comprehension, score 2 for severe fragmentation, score 3 for mute/global aphasia.
Group A - Patient 1 - Item 11: Extinction/Inattention (Double Simultaneous Stimulation):
On double simultaneous stimulation, patient perceives visual, tactile, and auditory stimuli on
both sides when stimulated simultaneously. No extinction or neglect noted.
A. 1 - Neglect in one modality
B. 0 - No neglect [CORRECT]
C. 2 - Profound neglect (more than one modality)
D. NT - Not testable
Correct Answer: B
Rationale: Patient has no neglect or extinction in any modality, scoring 0 per NINDS guidelines.
Score 1 for neglect in one modality (e.g., tactile extinction), score 2 for profound neglect in more
than one modality.
Group A - Patient 2: Moderate Right Hemisphere Stroke (Left Hemiplegia, Left Hemianopia, Left
Neglect, Mild Dysarthria)
Group A - Patient 2 - Item 1a: Level of Consciousness (LOC):
Patient is awake and alert, responding immediately to the examiner's questions without any
need for repetitive or painful stimulation.
A. 2 - Not alert, requires repeated stimulation to attend
B. 3 - Unresponsive or responds only with reflex motor effects
C. 0 - Alert, keenly responsive [CORRECT]
D. 1 - Not alert but arousable by minor stimulation
Correct Answer: C
Rationale: Patient is fully awake and keenly responsive, scoring 0 per NIHSS 2026 certification
standards. Score 1 is for drowsiness requiring verbal stimulation, score 2 for obtundation
requiring tactile stimulation, score 3 for coma.
Group A - Patient 2 - Item 1b: LOC Questions (Month and Age):
Patient is alert. When asked "What month is it?" patient responds "March" (correct). When
asked "How old are you?" patient responds "68" (correct).
