A nurse is caring for a patient who was just admitted with a head injury. The physician orders a Glasgow Coma Scale (GCS) assessment. The nurse observes that the patient opens their eyes to verbal stimuli, responds with inappropriate words, and localizes pain by withdrawing the limb. What GCS score should the nurse document? A) 8 B) 10 C) 12 D) 14 E) 15 Correct Answer: C) 12

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Rationale 1: The GCS assesses a patient’s level of consciousness based on eye opening, verbal response, and motor response. In this case, the patient opens their eyes to verbal stimuli (4 points), responds with inappropriate words (3 points), and localizes pain by withdrawing the limb (5 points), resulting in a GCS score of 12.

Understanding the Glasgow Coma Score: NCLEX Priority Questions

A patient is admitted with a traumatic brain injury. During the GCS assessment, the nurse notes that the patient opens their eyes spontaneously, utters incoherent words, and exhibits decerebrate posturing. What GCS score should the nurse assign? A) 5 B) 8 C) 10 D) 14 E) 15 Correct Answer: D) 14

Rationale 2: In this scenario, the patient’s spontaneous eye opening scores 4 points, incoherent words score 2 points, and decerebrate posturing scores 4 points. The total GCS score is 10, reflecting a moderate level of impairment in consciousness.

Understanding Glasgow Coma Score: NCLEX Delegation Questions

A nurse is assessing a patient postoperatively following neurosurgery. The patient opens their eyes in response to painful stimuli, responds with incomprehensible sounds, and exhibits decorticate posturing. What GCS score should the nurse document? A) 7 B) 9 C) 11 D) 13 E) 15 Correct Answer: A) 7

Rationale 3: In this case, the patient’s response to painful stimuli scores 2 points, incomprehensible sounds score 2 points, and decorticate posturing scores 3 points. The total GCS score is 7, indicating a severe impairment of consciousness. Decorticate posturing reflects damage to the cerebral hemispheres.

Understanding Glasgow Coma Score: Causes and Symptoms

A nurse is caring for a patient who has been in a coma for several days following a traumatic brain injury. The family asks the nurse about signs of potential improvement in the patient’s condition. Which neurological sign is indicative of emerging consciousness in a patient recovering from a coma? A) Decerebrate posturing B) Absence of cranial reflexes C) Purposeful movement in response to stimuli D) Fixed and dilated pupils E) Absence of deep tendon reflexes Correct Answer: C) Purposeful movement in response to stimuli

Rationale 1: Purposeful movement in response to stimuli, such as following simple commands, is indicative of emerging consciousness in a patient recovering from a coma. This signifies a higher level of neurological function compared to the other options, suggesting a positive trend in the patient’s condition.

NCLEX Practice Questions: Understanding Glasgow Coma Score Causes and Symptoms

A patient has been in a coma for an extended period. The nurse observes that the patient’s eyes are closed, and there is no response to verbal or painful stimuli. Which type of coma does this presentation most likely indicate? A) Locked-in syndrome B) Persistent vegetative state C) Brainstem herniation D) Subarachnoid hemorrhage E) Metabolic encephalopathy Correct Answer: B) Persistent vegetative state

Rationale 2: A persistent vegetative state is characterized by the absence of purposeful responses to stimuli, including no eye opening or response to verbal or painful stimuli. This condition indicates severe impairment of consciousness and is often associated with significant brain damage.

NCLEX Questions: Focus on Medications, Glasgow Coma Score

A nurse is assessing a patient in a coma. The patient displays decerebrate posturing and exhibits fixed, dilated pupils. What does this neurological presentation suggest about the patient’s condition? A) Impending recovery from the coma B) Intact brainstem function C) Hypoxic brain injury D) Cerebral herniation E) Normal physiological response to coma Correct Answer: D) Cerebral herniation

Rationale 3: Decerebrate posturing and fixed, dilated pupils are indicative of increased intracranial pressure and cerebral herniation. This neurological presentation suggests a serious and potentially life-threatening condition, requiring prompt intervention to alleviate pressure on the brain and prevent further damage.

NCLEX Focus Exploring Glasgow Coma Score: Causes and Diagnosis

A nurse is assessing a patient in the emergency department who sustained a head injury in a motor vehicle accident. The patient opens their eyes spontaneously, utters inappropriate words, and withdraws from painful stimuli. What Glasgow Coma Scale (GCS) score should the nurse assign to this patient? A) 7 B) 9 C) 11 D) 13 E) 15 Correct Answer: C) 11

Rationale 1: In this scenario, the patient’s spontaneous eye opening scores 4 points, inappropriate words score 3 points, and withdrawal from painful stimuli scores 4 points. The total GCS score is 11, indicating a moderate impairment of consciousness.

A nurse is caring for a postoperative patient who opens their eyes in response to verbal stimuli, responds with confused words, and exhibits decorticate posturing. What GCS score should the nurse document? A) 6 B) 8 C) 10 D) 12 E) 14 Correct Answer: B) 8

Rationale 2: In this case, the patient’s response to verbal stimuli scores 3 points, confused words score 3 points, and decorticate posturing scores 2 points. The total GCS score is 8, indicating a severe impairment of consciousness.

NCLEX Review: Glasgow Coma Score

A patient is admitted with a head injury. During the GCS assessment, the nurse notes that the patient opens their eyes to painful stimuli, mumbles incomprehensibly, and exhibits decerebrate posturing. What GCS score should the nurse assign? A) 5 B) 7 C) 9 D) 11 E) 13 Correct Answer: A) 5

Rationale 3: In this scenario, the patient’s response to painful stimuli scores 2 points, incomprehensible sounds score 2 points, and decerebrate posturing scores 1 point. The total GCS score is 5, indicating a very severe impairment of consciousness.

NCLEX Focus Exploring Glasgow Coma Score: Causes and Diagnosis

A nurse is assessing a patient who is unresponsive. The patient does not open their eyes, makes no verbal responses, and exhibits no motor responses to stimuli. What GCS score should the nurse assign? A) 3 B) 5 C) 7 D) 9 E) 12 Correct Answer: A) 3

Rationale 4: In this situation, the patient’s lack of eye opening, verbal responses, and motor responses results in a GCS score of 3, reflecting the most severe impairment of consciousness. This score suggests a deep coma state requiring immediate attention and intervention.