Medical Surgical Glasgow Coma Scale GCS #2

Question

The Glasgow Coma Scale assesses which of the following specifications related to neurological status with traumatic brain injuries. Select all that apply.

Answers

  1. 1. Best motor responses
    • Rationale:

      This answer is correct because the GCS assesses best eye opening response, best verbal response, and best motor response. Motor Response: obeys commands for movement 6 points; purposeful movement to painful stimulus 5 points; withdraws in response to pain 4 points; flexion in response to pain (decorticate posturing) 3 points; extension response in response to pain (decerebrate posturing) 2 points, and no response 1 point.

  2. 2. Best verbal responses
    • Rationale:

      This answer is correct because the GCS assesses best eye opening response, best verbal response, and best motor response. Verbal Response: oriented 5 points; confused conversation, but able to answer questions 4 points; inappropriate words 3 points; incomprehensible speech 2 points; and no response 1 point.

  3. 3. Best memory response
    • Rationale:

      This answer is not correct because the best memory responses are not tested on the GCS. The GCS assesses best eye opening response, best verbal response, and best motor response.

  4. 4. Best eye responses
    • Rationale:

      This answer is correct because the GCS assesses best eye opening response, best verbal response, and best motor response. Eye Opening Response: Spontaneous–open with blinking at baseline 4 points; to verbal stimuli, command, speech 3 points; to pain only (not applied to face) 2 points; and no response 1 point.

  5. 5. Best leg responses
    • Rationale:

      This answer is not correct because the best leg responses are not tested on the GCS. The GCS assesses best eye opening response, best verbal response, and best motor response.

Overview

The GCS assesses best eye opening response, best verbal response, and best motor response. Eye Opening Response: Spontaneous–open with blinking at baseline 4 points; to verbal stimuli, command, speech 3 points; to pain only (not applied to face) 2 points; and no response 1 point; Verbal Response: oriented 5 points; confused conversation, but able to answer questions 4 points; inappropriate words 3 points; incomprehensible speech 2 points; and no response 1 point; Motor Response: obeys commands for movement 6 points; purposeful movement to painful stimulus 5 points; withdraws in response to pain 4 points; flexion in response to pain (decorticate posturing) 3 points; extension response in response to pain (decerebrate posturing) 2 points, and no response 1 point. To calculate a client’s total GCS, add each of the points together beginning with eye opening, verbal response, and motor response.

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

When caring for any client, level of consciousness is important to determine arousability and responsiveness to the environment. Through assessing level of consciousness, one can determine how neurologically intact or if the client has a deficit with traumatic brain injuries.

Video Rationale