Glasgow Coma Scale Assessment Quiz

The Glasgow Coma Scale (GCS) assesses what areas of response to stimuli? Select all that apply

• Auditory response

• Verbal response

• Tactile response

• Eye-opening response

• Motor response

During the Glasgow Coma Scale (GCS) assessment the nurse applies a central painful stimulus to test the best motor response. Which of the following is NOT this type of stimulus?

• Trapezius squeeze

• Fingernail bed pressure

• Supraorbital pressure

A patient has experienced a brain injury. You note that written in the progress notes the physician says the patient has a GCS 10 (E3 V3 M4). What is the level of brain injury in this patient?(Required)

• Mild brain injury

• Moderate brain injury

• Severe brain injury

What Glasgow Coma Scale score usually requires intubation because the airway reflexes are affected?(Required)

• 10 or less

• 9 or greater

• 8 or less

• 10 or greater

True or False: The nurse is assessing the Glasgow Coma Scale in a patient, but is unable to assess the best verbal response due to intubation. Therefore, the nurse should assigned 1 point for the best verbal response.(Required)

• True

• False

A patient with a traumatic brain injury has sustained multiple fractures to the face and eyes. When testing the best motor response, the nurse notes the patient is unable to perform a motor command based on a verbal stimulus. The nurse attempts to use a pressure stimulus to test the motor response. What type of pressure or painful stimuli should the nurse avoid in this patient?(Required)

• Fingernail bed pressure

• Trapezius squeeze

• Supraorbital pressure

• Toenail bed pressure

You’re assessing a patient's Glasgow Coma Scale at the bedside. What is the patient’s score based on these findings: when you arrive to the patient’s bedside the patient is looking around, the patient tells you they are at a concert hall and the year is 1960 (it is 2022) but they state their correct name, and they are able to open their mouth and stick out their tongue.(Required)

• GCS 14 (E4 V4 M6)

• GCS 11 (E3 V3 M5)

• GCS 15 (E4 V5 M6)

• GCS 13 (E4 V3 M6)

You’re assessing a patient's Glasgow Coma Scale at the bedside. What is the patient’s score based on these findings: when you arrive to the patient’s bedside the patient’s eyes are closed, but they open when you speak to the patient, the patient doesn’t respond appropriately to questions asked and says words that don’t make sense. In addition, the patient can’t obey a motor command. Therefore, when you apply a central stimulus the patient moves to locate and remove the stimulus.(Required)

• GCS 12 (E3 V4 M5)

• GCS 8 (E2 V4 M2)

• GCS 11 (E3 V3 M5)

• GCS 10 (E3 V3 M4)

You’re assessing a patient's Glasgow Coma Scale at the bedside. What is the patient’s score based on these findings: when you arrive to the patient’s bedside the patient’s eyes are closed but they open when you speak to the patient. The nurse cannot assess best verbal response because the patient is intubated. In addition, the patient can’t obey a motor command. Therefore, when you apply a central stimulus the patient flexes to withdraw from the stimulus.(Required)

• GCS 8 (E3 V1 M4)

• GCS 7T (E3 Vt M4)

• GCS 9 (E3 V1 M5)

• GCS 6T (E3 Vt M3)

You’re assessing a patient's Glasgow Coma Scale at the bedside. What is the patient’s score based on these findings: when you arrive to the patient’s bedside the patient’s eyes are closed and don’t open when spoken to. The nurse applies a peripheral painful stimulus, and the patient’s eyes open. When asked questions the patient groans and moans noises. In addition, the patient can’t obey a motor command. Therefore, when you apply a central stimulus the patient flexes to withdraw from the stimulus.(Required)

• GCS 12 (E3 V4 M5)

• GCS 8 (E2 V4 M2)

• GCS 8 (E2 V2 M4)

• GCS 10 (E3 V3 M4)