Nihss Stroke Scale Test A Answers

NIHSS stroke scale test A answers provide a quick, standardized way to quantify neurological deficit in patients with suspected acute stroke. Understanding how each item is scored and what the correct responses look like is essential for clinicians, emergency staff, and trainees who need to act fast while maintaining accuracy. This guide walks through the purpose of the NIHSS, breaks down Test A item‑by‑item, supplies exemplar answers with scoring rationale, and offers practical tips to avoid common pitfalls.

What Is the NIHSS?

The National Institutes of Health Stroke Scale (NIHSS) is a 15‑item neurological examination designed to measure the severity of stroke symptoms. Each item evaluates a specific domain—such as level of consciousness, gaze, visual fields, facial palsy, motor strength, limb ataxia, sensation, language, dysarthria, and extinction/inattention. Scores range from 0 (no deficit) to a maximum of 42, with higher numbers indicating greater impairment. The scale is widely used in emergency departments, stroke units, and research trials because it is reliable, quick to administer (typically 5–8 minutes), and correlates well with clinical outcomes.

Overview of NIHSS Test A

Test A is one of several standardized versions of the NIHSS that present the same items in a fixed order but use different stimulus materials (e.g., distinct pictures for the visual‑field and language sections). The purpose of having multiple forms is to reduce learning effects when the scale is repeated over time. While the items themselves do not change, the specific pictures, sentences, or commands differ between forms. Knowing the correct answers for Test A ensures that scoring is consistent across examiners and sessions.

Below is a detailed walk‑through of each NIHSS item as it appears in Test A, including the expected patient response, the scoring criteria, and a brief explanation of why that answer earns the given points.

Item‑by‑Item Breakdown of NIHSS Test A

1. Level of Consciousness (LOC) – Questions & Commands

• Question 1a: “What is the month? What is your age?”
  Correct answer: Patient states the current month and their age accurately.
  Score: 0 if both are correct; 1 if one is wrong; 2 if both are wrong or patient cannot speak.
• Question 1b: “Open and close your eyes. Then grip and release my hand.”
  Correct answer: Patient follows both commands without hesitation.
  Score: 0 if both commands obeyed; 1 if one command is performed; 2 if neither is performed.

2. LOC – Best Gaze

• Instruction: “Look left, then right. Follow my finger.”
  Correct answer: Smooth horizontal eye movements to both sides with no deviation or jerking.
  Score: 0 for normal gaze; 1 for partial gaze palsy (difficulty looking to one side); 2 for forced deviation or total gaze palsy.

3. Visual Fields

• Stimulus: Confrontation testing using the examiner’s fingers in the four quadrants (shown on Test A picture card).
  Correct answer: Patient correctly identifies the number of fingers shown in each quadrant.
  Score: 0 for no visual loss; 1 for partial hemianopia; 2 for complete hemianopia; 3 for bilateral hemianopia (cortical blindness).

4. Facial Palsy

• Instruction: “Show your teeth or raise your eyebrows.”
  Correct answer: Symmetrical movement of both sides of the face.
  Score: 0 for normal symmetry; 1 for minor asymmetry (e.g., slight flattening of nasolabial fold); 2 for partial paralysis (lower face only); 3 for complete paralysis of one side.

5. Motor Arm – Left

• Instruction: “Extend your arm out to 90° (if sitting) or 45° (if supine) and hold it for 10 seconds.”
  Correct answer: Limb holds position without drift.
  Score: 0 for no drift; 1 for drift before 10 seconds but does not fall; 2 for falls before 5 seconds; 3 for no effort against gravity; 4 for no movement.

6. Motor Arm – Right

• Same procedure as item 5, scored identically.

7. Motor Leg – Left

• Instruction: “Lift your leg to 30° (if sitting) or 45° (if supine) and hold for 5 seconds.”
  Scoring: Mirrors arm items (0–4) based on drift and effort.

8. Motor Leg – Right

• Same as item 7.

9. Limb Ataxia

• Instruction: Finger‑to‑nose test (left hand) and heel‑to‑shin test (left leg), then repeat on right side.
  Correct answer: Smooth, coordinated movement without dysmetria.
  Score: 0 for absent; 1 for present in one limb; 2 for present in two limbs.

10. Sensory

• Stimulus: Pinprick stimulation of the face, arm, and leg on both sides (using the Test A sensory card).
  Correct answer: Patient reports sensation as “sharp” equally on both sides.
  Score: 0 for normal; 1 for mild-to‑moderate loss; 2 for severe to total loss.

11. Best Language

• Sub‑items:
  • Picture description (using the Test A picture sheet).
  • Naming (showing objects on the naming sheet).
  • Repetition (asking the patient to repeat a list of sentences).
    Correct answer: Patient describes the picture fluently, names objects without error, and repeats sentences accurately.
    Score: 0 for no aphasia; 1 for mild‑to‑moderate aphasia (some word‑finding difficulty); 2 for severe aphasia (limited verbal output); 3 for mute, global aphasia; 4 for intubated/other barrier (not applicable in Test A).

12. Dysarthria

• Instruction: Patient reads a standard sentence or repeats words.

12. Dysarthria (Continued)

• Instruction: Patient reads a standard sentence or repeats words. Correct answer: Articulation is clear and understandable.
  Score: 0 for normal; 1 for mild slurring or difficulty with certain sounds; 2 for moderate slurring or significant difficulty with articulation; 3 for severe slurring, unintelligible speech; 4 for intubated/other barrier (not applicable in Test A).

13. Reflexes

• Stimulus: Assessment of deep tendon reflexes (biceps, triceps, brachioradialis, patellar, Achilles) using a reflex hammer. Correct answer: Normal reflexes are brisk and symmetrical.
  Score: 0 for normal; 1 for hyporeflexia (diminished reflex); 2 for areflexia (absent reflex); 3 for hyperreflexia (exaggerated reflex); 4 for clonus (rhythmic muscle contractions).

14. Coordination

• Instruction: Finger-to-nose test (right hand) and heel-to-shin test (right leg), then repeat on left side. Correct answer: Smooth, coordinated movement without dysmetria. Score: 0 for absent; 1 for present in one limb; 2 for present in two limbs.

15. Gait

• Observation: Patient walks a specified distance (e.g., 10 feet) with minimal assistance. Correct answer: Steady, balanced gait with normal step length and cadence. Score: 0 for normal; 1 for mild instability; 2 for moderate instability; 3 for severe instability; 4 for inability to walk.

Total Score Interpretation:

• 0-16 Points: Normal neurological function.
• 17-32 Points: Mild neurological impairment.
• 33-48 Points: Moderate neurological impairment.
• 49-64 Points: Significant neurological impairment.
• 65-80 Points: Severe neurological impairment.

Important Note: This scoring system is a simplified guide and should be used in conjunction with a thorough neurological examination and clinical judgment. Individual variations and underlying conditions can influence results. The Test A protocol is designed to provide a rapid assessment of key neurological functions, but it does not replace a comprehensive neurological evaluation.

Conclusion:

The Test A protocol offers a valuable, streamlined approach to assessing a range of neurological functions in a relatively short timeframe. Its structured format, utilizing visual and motor tasks alongside sensory and language evaluations, provides a broad overview of potential impairments. While the scoring system offers a quantitative measure, the true value of Test A lies in its ability to quickly identify areas of concern, prompting further investigation and guiding the development of a tailored rehabilitation plan. Ultimately, this tool serves as a crucial initial step in the neurological assessment process, facilitating a more detailed and comprehensive understanding of the patient’s condition and guiding their journey toward optimal recovery.