Medical Surgical Glasgow Coma Scale GCS #3

Question

A nurse is assessing a client’s level of consciousness for an unresponsive client. The nurse assesses that the client does not open the eyes; makes incomprehensible sounds; and has abnormal flexion of the extremities. What would the client’s Glasgow Coma Scale score be?

Answers

  1. A score of 3
    • Rationale:

      This answer is not correct because the client is unresponsive with no response to eye opening which is 1 point; has incomprehensible speech which is 2 points; and has abnormal flexion of the extremities, which is 3 points for a GCS of 6.

  2. A score of 4
    • Rationale:

      This answer is not correct because the client is unresponsive with no response to eye opening which is 1 point; has incomprehensible speech which is 2 points; and has abnormal flexion of the extremities, which is 3 points for a GCS of 6.

  3. A score of 5
    • Rationale:

      This answer is not correct because the client is unresponsive with no response to eye opening which is 1 point; has incomprehensible speech which is 2 points; and has abnormal flexion of the extremities, which is 3 points for a GCS of 6.

  4. A score of 6
    • Rationale:

      This answer is correct because the client is unresponsive with no response to eye opening which is 1 point; has incomprehensible speech which is 2 points; and has abnormal flexion of the extremities, which is 3 points for a GCS of 6.

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

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.

Test Taking Tip

Read each question carefully. Do not spend too much time on any one question. You can skip a question and come back to the question after you have answered what you know. Take your time to think of the answer(s) before actually looking at the answer options.

Video Rationale