1. A nurse is assessing a client with a brain injury using the Glasgow Coma Scale (GCS). The client does not open their eyes, makes no sounds, and makes no movements. How would the nurse score the client using the GCS?
a.6
b. 16
c. 3
d. 5
2. A client is fully awake, knows the date, who they are, and where they are. Which charting statement would most accurately reflect this assessment?
a. Alert; oriented x 3
b. Alert; fully oriented
c. Responds to pain; oriented x 3
d. Respond to verbal stimuli; oriented x 2
3. A nurse is inspecting a client’s eyes. Which assessment should the nurse complete first?
a. Pupil response to light
b. Baseline pupil size and shape
c. Cardinal fields of vision
d. Administer the Snellen chart
1. C(3) no eye response no verbal response no motor response. So score is minimum 1+1+1=3
GCS SCALE:
Eye Opening (E)
Verbal Response (V)
Motor Response (M)
2. A alert and oriented *3
X1 means “oriented to self or person” – patient knows own name,
significant others.
X2 means “oriented to person and place” – knows where he/she is. X3
means “oriented to person, place, and time” – knows the
date/day.
3. D smell chart
The key to any examination is to be systematic and always perform each element.
1. Visual acuity
2. Pupils
3. Extraocular motility and alignment
Intraocular pressure
5. Confrontation visual fields
6. External examination
1. A nurse is assessing a client with a brain injury using the Glasgow Coma Scale...
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