National Institutes of Health
MAXE • SSHIN
NIH NIH Stroke Scale (NIHSS) Program
S C I E N C E • H E A LT H • H U M A N I T Y
EST. 2026
NIH Stroke Scale — Quick Reference Examination
CO R E CO M P O N E N TS , S CO R I N G & N E U R O LO G I C A L A SS E SS M E N T
INSTITUTION National Institutes of Health (NIH) PROGRAM NIHSS Stroke Certification
ACADEMIC YEAR EXAM TITLE NIH Stroke Scale — Core Components
Exam
TOTAL QUESTIONS 14 Questions FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question covering the 13 core NIHSS components.
▸ Questions assess knowledge of each scale item, its purpose, administration technique, and scoring significance.
▸ Pay close attention to the specific testing methods and what neurological function each item evaluates.
▸ Correct answers and detailed rationales appear below each question for certification study.
▸ The NIHSS total score ranges from 0 (normal) to 42 (maximum severity).
SECTION I — NIH STROKE SCALE: ALL 13 COMPONENTS Questions 1 – 14
1. What is the NIH Stroke Scale (NIHSS)?
A. A blood test that measures stroke biomarkers
B. A systematic tool used by healthcare providers to objectively quantify the impairment caused by an acute ischemic
stroke
C. An imaging protocol for CT scans
D. A surgical technique for removing blood clots
CORRECT ANSWER B — A systematic tool used by healthcare providers to objectively quantify the impairment caused by
an acute ischemic stroke
RATIONALE The NIH Stroke Scale (NIHSS) is a standardized, systematic assessment tool that quantifies neurological
deficit severity in acute ischemic stroke patients. It was developed by the National Institutes of Health and is
now the gold standard for stroke assessment worldwide. The NIHSS provides an objective, reproducible
numerical score (0–42) that can be used to: determine stroke severity, guide treatment decisions (including
tPA eligibility), monitor neurological changes over time (improvement or deterioration), predict patient
outcomes, and facilitate communication among healthcare providers. It is used in the emergency
department, inpatient settings, and clinical research trials to standardize stroke assessment across
institutions.
, 2. What does Item 1 (Level of Consciousness) assess?
A. The patient's ability to name objects
B. Whether the patient is alert, drowsy, or comatose
C. The patient's visual fields
D. Facial symmetry during smiling
CORRECT ANSWER B — Whether the patient is alert, drowsy, or comatose
RATIONALE Item 1 (Level of Consciousness) is the first assessment on the NIHSS and establishes the patient's baseline
arousal state. It consists of three sub-items: 1A evaluates responsiveness to stimuli (ranging from alert to
completely unresponsive), 1B tests orientation by asking two questions ("What month is it?" and "How old are
you?"), and 1C tests the ability to follow simple commands ("Open and close your eyes" and "Squeeze and
release my hand"). The LOC assessment is fundamental because the patient's arousal level affects the
reliability and scoring of all subsequent items. A severely depressed level of consciousness (score 3 on 1A)
triggers default coma scores for items that cannot be tested.
3. What is evaluated in Item 2 (Best Gaze)?
A. Pupillary light reflex
B. Horizontal eye movement to check for conjugate deviation or inability to track objects
C. Visual acuity using an eye chart
D. Color vision discrimination
CORRECT ANSWER B — Horizontal eye movement to check for conjugate deviation or inability to track objects
RATIONALE Item 2 (Best Gaze) tests ONLY horizontal eye movements, assessing both voluntary (command) and reflexive
(oculocephalic/doll's eyes) eye movements. The examiner moves a pen or finger from side to side and
observes the patient's ability to track smoothly across the midline. This item detects conjugate gaze
deviation, which occurs in approximately 20% of acute strokes — the patient's eyes are deviated toward the
lesion (ipsilateral hemisphere) and away from the hemiparesis. This is caused by unopposed action of the
frontal eye fields in the unaffected hemisphere. Scoring ranges from 0 (normal) to 2 (forced gaze deviation/
total gaze paresis). Vertical eye movements are not tested.
4. How are Visual Fields (Item 3) tested on the NIHSS?
A. By performing a fundoscopic examination
B. By testing for hemianopia or quadrantanopia using finger counting in different quadrants
C. By having the patient read progressively smaller lines of text
D. By measuring intraocular pressure
CORRECT ANSWER B — By testing for hemianopia or quadrantanopia using finger counting in different quadrants
RATIONALE Item 3 (Visual Fields) is tested by confrontation in all four quadrants (upper and lower, left and right visual
fields). Each eye is tested individually while the other is covered. The examiner holds up a specific number of
fingers in each quadrant and asks the patient to count them. For non-responsive patients, visual threat
(moving an object toward the eye) is used to elicit a blink response. Scoring: 0 = No vision loss; 1 = Partial
hemianopia or complete quadrantanopia; 2 = Complete hemianopia; 3 = Bilateral blindness. This item detects
visual field deficits commonly associated with posterior cerebral artery (PCA) strokes affecting the occipital
lobe or optic radiations. The deficit must be attributable to the stroke.
MAXE • SSHIN
NIH NIH Stroke Scale (NIHSS) Program
S C I E N C E • H E A LT H • H U M A N I T Y
EST. 2026
NIH Stroke Scale — Quick Reference Examination
CO R E CO M P O N E N TS , S CO R I N G & N E U R O LO G I C A L A SS E SS M E N T
INSTITUTION National Institutes of Health (NIH) PROGRAM NIHSS Stroke Certification
ACADEMIC YEAR EXAM TITLE NIH Stroke Scale — Core Components
Exam
TOTAL QUESTIONS 14 Questions FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question covering the 13 core NIHSS components.
▸ Questions assess knowledge of each scale item, its purpose, administration technique, and scoring significance.
▸ Pay close attention to the specific testing methods and what neurological function each item evaluates.
▸ Correct answers and detailed rationales appear below each question for certification study.
▸ The NIHSS total score ranges from 0 (normal) to 42 (maximum severity).
SECTION I — NIH STROKE SCALE: ALL 13 COMPONENTS Questions 1 – 14
1. What is the NIH Stroke Scale (NIHSS)?
A. A blood test that measures stroke biomarkers
B. A systematic tool used by healthcare providers to objectively quantify the impairment caused by an acute ischemic
stroke
C. An imaging protocol for CT scans
D. A surgical technique for removing blood clots
CORRECT ANSWER B — A systematic tool used by healthcare providers to objectively quantify the impairment caused by
an acute ischemic stroke
RATIONALE The NIH Stroke Scale (NIHSS) is a standardized, systematic assessment tool that quantifies neurological
deficit severity in acute ischemic stroke patients. It was developed by the National Institutes of Health and is
now the gold standard for stroke assessment worldwide. The NIHSS provides an objective, reproducible
numerical score (0–42) that can be used to: determine stroke severity, guide treatment decisions (including
tPA eligibility), monitor neurological changes over time (improvement or deterioration), predict patient
outcomes, and facilitate communication among healthcare providers. It is used in the emergency
department, inpatient settings, and clinical research trials to standardize stroke assessment across
institutions.
, 2. What does Item 1 (Level of Consciousness) assess?
A. The patient's ability to name objects
B. Whether the patient is alert, drowsy, or comatose
C. The patient's visual fields
D. Facial symmetry during smiling
CORRECT ANSWER B — Whether the patient is alert, drowsy, or comatose
RATIONALE Item 1 (Level of Consciousness) is the first assessment on the NIHSS and establishes the patient's baseline
arousal state. It consists of three sub-items: 1A evaluates responsiveness to stimuli (ranging from alert to
completely unresponsive), 1B tests orientation by asking two questions ("What month is it?" and "How old are
you?"), and 1C tests the ability to follow simple commands ("Open and close your eyes" and "Squeeze and
release my hand"). The LOC assessment is fundamental because the patient's arousal level affects the
reliability and scoring of all subsequent items. A severely depressed level of consciousness (score 3 on 1A)
triggers default coma scores for items that cannot be tested.
3. What is evaluated in Item 2 (Best Gaze)?
A. Pupillary light reflex
B. Horizontal eye movement to check for conjugate deviation or inability to track objects
C. Visual acuity using an eye chart
D. Color vision discrimination
CORRECT ANSWER B — Horizontal eye movement to check for conjugate deviation or inability to track objects
RATIONALE Item 2 (Best Gaze) tests ONLY horizontal eye movements, assessing both voluntary (command) and reflexive
(oculocephalic/doll's eyes) eye movements. The examiner moves a pen or finger from side to side and
observes the patient's ability to track smoothly across the midline. This item detects conjugate gaze
deviation, which occurs in approximately 20% of acute strokes — the patient's eyes are deviated toward the
lesion (ipsilateral hemisphere) and away from the hemiparesis. This is caused by unopposed action of the
frontal eye fields in the unaffected hemisphere. Scoring ranges from 0 (normal) to 2 (forced gaze deviation/
total gaze paresis). Vertical eye movements are not tested.
4. How are Visual Fields (Item 3) tested on the NIHSS?
A. By performing a fundoscopic examination
B. By testing for hemianopia or quadrantanopia using finger counting in different quadrants
C. By having the patient read progressively smaller lines of text
D. By measuring intraocular pressure
CORRECT ANSWER B — By testing for hemianopia or quadrantanopia using finger counting in different quadrants
RATIONALE Item 3 (Visual Fields) is tested by confrontation in all four quadrants (upper and lower, left and right visual
fields). Each eye is tested individually while the other is covered. The examiner holds up a specific number of
fingers in each quadrant and asks the patient to count them. For non-responsive patients, visual threat
(moving an object toward the eye) is used to elicit a blink response. Scoring: 0 = No vision loss; 1 = Partial
hemianopia or complete quadrantanopia; 2 = Complete hemianopia; 3 = Bilateral blindness. This item detects
visual field deficits commonly associated with posterior cerebral artery (PCA) strokes affecting the occipital
lobe or optic radiations. The deficit must be attributable to the stroke.
