Medical Surgical Glasgow Coma Scale GCS #1

Question

The nurse is caring for a client with a Glasgow coma scale of 5. What finding would the nurse expect with a coma scale of 5?

Answers

  1. The client is alert & oriented X 4
    • Rationale:

      This answer is not correct because if the client was alert & oriented x 4, the client’s GCS would be 15. This is a normal GCS where no injury is found.

  2. The client is alert but confused
    • Rationale:

      This answer is not correct because if the client was alert and confused, the client’s GCS could be 9-12, where moderate injury is found..

  3. The client is severely confused
    • Rationale:

      This answer is not correct because if the client was alert and severely confused, the client’s GCS could be between 9-12, where moderate injury is found..

  4. The client is in a coma
    • Rationale:

      This answer is correct because with a GCS of 5, the client has severe brain injury and would be found comatose.

Overview

The total Glasgow coma scale (GCS) highest score is 15, which is considered normal brain activity. If the client’s GCS is less than 8, the client is considered neurologically unstable, a medical emergency, and will be placed in the intensive care unit. The GCS assesses best eye opening response, best verbal response, and best motor response. When a client’s GCS is 13-15, the client has mild brain injury; a GCS of 9-12 indicates moderate brain injury; and a GCS of 3-8 is severe brain injury. If the client has a GCS of 5, the client would be found comatose.

Explanation

Learning Outcomes

The Glasgow coma scale is a 3-15 point scale which helps to determine level of consciousness or neurological status for the client with a traumatic brain injury. The total Glasgow coma scale (GCS) highest score is 15, which is considered normal brain activity. If the client’s GCS is less than 8, the client is considered neurologically unstable, a medical emergency, and will be placed in the intensive care unit. When a client’s GCS is 13-15, the client has mild brain injury; a GCS of 9-12 indicates moderate brain injury; and a GCS of 3-8 is severe brain injury.

Test Taking Tip

Assessing a client’s neurological status by using the Glascow Coma Scale (GCS) is very important with traumatic brain injuries to determine level of consciousness and how bad the injury is.

Video Rationale