Chamberlain University
1 MAXE • 403 RN
★ ★
C College of Nursing
J O U R N E Y T O E X T R A O R D I N A R Y CO M PA S S I O N AT E C A R E
EST. 1889
NR 304 — Examination 1
H E A LT H A SS E SS M E N T: N E U R O LO G I C A L SYST E M , G CS , C R A N I A L N E R V E S & ST R O K E
INSTITUTION Chamberlain University COURSE CODE NR 304
PROGRAM Bachelor of Science in Nursing (BSN) ACADEMIC YEAR
EXAM TITLE Examination 1 — Health Assessment TOTAL QUESTIONS 55 Questions
COURSE TITLE Health Assessment FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise instructed.
▸ Glasgow Coma Scale (GCS) scoring — eye, verbal, and motor responses — is a core competency for neurological assessment.
▸ Cranial nerves I-XII with functions, assessment techniques, and clinical abnormalities are emphasized throughout.
▸ Deep tendon reflex grading (0-4+), posturing (decorticate/decerebrate), and neurological disorders are testable content.
▸ Stroke recognition using BE FAST, ischemic vs. hemorrhagic stroke differentiation, and emergency treatment are critical
knowledge areas.
▸ Correct answers and clinical rationales appear below each question for NCLEX board review purposes.
▸ All content reflects current AHA/ASA stroke guidelines and evidence-based neurological assessment standards.
SECTION I — GLASGOW COMA SCALE (GCS): EYE, VERBAL & MOTOR Questions 1 –
RESPONSES 15
1. GCS eyes score 4 indicates what response?
A. Response to pain
B. Response to speech
C. Spontaneous response — eyes open spontaneously without any stimulus
D. No response
CORRECT ANSWER C — Spontaneous response; eyes open spontaneously without any stimulus; best possible eye
response
RATIONALE A GCS eye score of 4 is the maximum score for eye opening — the patient opens their eyes spontaneously
without any external stimulus. This indicates intact function of the reticular activating system in the
brainstem, which controls arousal and wakefulness. Spontaneous eye opening means the patient is awake
and aware, though they may not be fully oriented. The eye response component of the GCS ranges from 1 (no
eye opening) to 4 (spontaneous). Scores of 3 (to speech), 2 (to pain), and 1 (none) indicate progressively
decreasing levels of consciousness and more severe brain dysfunction. The full GCS (E+V+M) ranges from 3-15.
,2. GCS eyes score 3 indicates what response?
A. Spontaneous response
B. Response to speech (to verbal command) — eyes open when called or spoken to
C. Response to pain
D. No response
CORRECT ANSWER B — Response to speech (to verbal command); eyes open when called or spoken to
RATIONALE A GCS eye score of 3 indicates the patient opens their eyes in response to verbal stimuli — when their name is
called or a command is given. This means the patient does NOT spontaneously open their eyes but will do so
when spoken to, indicating the brainstem reticular activating system can be aroused by auditory input. The
nurse should use a normal tone first, then a louder voice if no response. A score of 3 is one level below
spontaneous (4) and indicates a mild decrease in consciousness. If the patient only responds to loud noise or
shouting, this still falls under score 3 — it represents any verbal stimulus. If there is no response to voice but
the patient opens eyes to pain, the score drops to 2.
3. GCS eye score 2 indicates what response?
A. Spontaneous response
B. Response to speech
C. Response to pain — eyes open only to painful stimulus (e.g., sternal rub, nail bed pressure)
D. No response
CORRECT ANSWER C — Response to pain; eyes open only to painful stimulus (e.g., sternal rub, nail bed pressure); no
response to voice
RATIONALE A GCS eye score of 2 indicates the patient opens their eyes ONLY to a painful stimulus — there is no response
to verbal commands or normal speech. Painful stimuli used include sternal rub (rub knuckles firmly on the
sternum), nail bed pressure (apply pressure to the nail bed with a pen), or trapezius pinch. The patient does
NOT spontaneously open eyes and does NOT open eyes when spoken to. A score of 2 indicates significant
depression of consciousness — the brainstem is still responsive to noxious stimuli but not to auditory input. It
is important to apply a standardized painful stimulus and observe for eye opening (not just grimacing or
withdrawal). A score of 1 indicates no response at all.
4. GCS eye score 1 indicates what response?
A. Response to pain
B. Response to speech
C. Spontaneous response
D. No response — no eye opening to any stimulus; indicates severe brain dysfunction
CORRECT ANSWER D — No response; no eye opening to any stimulus; indicates severe brain dysfunction
RATIONALE A GCS eye score of 1 is the lowest possible eye score — the patient does NOT open their eyes to any stimulus,
including spontaneous, verbal, or painful stimuli. This indicates severe depression of the reticular activating
system and brainstem function, which is a grave prognostic sign. It may result from severe traumatic brain
injury, massive stroke, drug overdose, or post-cardiac arrest anoxic brain injury. Importantly, a score of 1 does
NOT necessarily indicate brain death — the patient may still have intact brainstem reflexes (pupillary, corneal,
gag). However, persistent eye score of 1 combined with absent motor and verbal responses (total GCS 3) in
the absence of sedation or neuromuscular blockade is consistent with brain death. All three GCS components
must be assessed together.
, 5. GCS verbal score 5 indicates what response?
A. Confused response
B. Oriented x4 (person, place, time, situation) — best possible verbal response
C. Inappropriate words
D. Incomprehensible sounds
CORRECT ANSWER B — Oriented x4 (person, place, time, situation); best possible verbal response
RATIONALE A GCS verbal score of 5 is the maximum verbal score — the patient is fully oriented to all four domains: Person
(knows their name), Place (knows where they are — hospital, city), Time (knows the date, day, month, year),
and Situation (understands why they are there). This indicates intact cognitive function and cortical
processing. The nurse assesses orientation by asking specific questions: "What is your name? Where are you
right now? What is today's date? Why are you here?" If the patient answers all correctly, they score a 5. If they
are conversant but confused or disoriented (can answer questions but answers are incorrect), the score drops
to 4. The verbal component is a key indicator of higher cortical function and is often the first GCS component
to decline with neurological deterioration.
6. GCS verbal score 4 indicates what response?
A. Oriented x4
B. Confused response — patient responds but is disoriented or confused; can answer questions but answers may be
incorrect
C. Inappropriate words
D. No response
CORRECT ANSWER B — Confused response; patient responds but is disoriented or confused; can answer questions but
answers may be incorrect
RATIONALE A GCS verbal score of 4 indicates the patient is conversant and can produce sentences, but is confused or
disoriented — they answer questions but get them wrong. For example, the patient may know their name but
think they are at home (not the hospital), or give the wrong year, or be unsure why they are there. The key
distinction from score 5 (oriented) is that the answers are incorrect. The patient's speech is fluent and
grammatically correct but the content is confused. This is common in acute confusional states (delirium),
dementia, post-ictal states, and metabolic encephalopathy. A score of 4 represents a mild-to-moderate
cognitive impairment. If the patient uses only random or inappropriate words rather than conversational
sentences, the score drops to 3.
7. GCS verbal response 3 indicates what response?
A. Confused conversation
B. Oriented x4
C. Inappropriate words — patient uses words but they are not appropriate to context; may consist of random or
incomprehensible words
D. No response
CORRECT ANSWER C — Inappropriate words; patient uses words but they are not appropriate to context; may consist of
random or incomprehensible words
RATIONALE A GCS verbal score of 3 indicates the patient produces recognizable words, but they are random,
inappropriate to the situation, or nonsensical — not coherent conversational speech. Examples: the patient
may swear repeatedly, repeat a single word, or produce words that have no relationship to the question
asked. The patient is NOT having a conversation and cannot answer questions meaningfully. This differs from
score 4 (confused conversation) where sentences are formed but content is incorrect, and from score 2
(incomprehensible sounds) where no recognizable words are produced. A score of 3 indicates significant
cortical dysfunction, often seen with severe traumatic brain injury, large stroke, or deep sedation. The nurse
documents exactly what the patient said.
1 MAXE • 403 RN
★ ★
C College of Nursing
J O U R N E Y T O E X T R A O R D I N A R Y CO M PA S S I O N AT E C A R E
EST. 1889
NR 304 — Examination 1
H E A LT H A SS E SS M E N T: N E U R O LO G I C A L SYST E M , G CS , C R A N I A L N E R V E S & ST R O K E
INSTITUTION Chamberlain University COURSE CODE NR 304
PROGRAM Bachelor of Science in Nursing (BSN) ACADEMIC YEAR
EXAM TITLE Examination 1 — Health Assessment TOTAL QUESTIONS 55 Questions
COURSE TITLE Health Assessment FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise instructed.
▸ Glasgow Coma Scale (GCS) scoring — eye, verbal, and motor responses — is a core competency for neurological assessment.
▸ Cranial nerves I-XII with functions, assessment techniques, and clinical abnormalities are emphasized throughout.
▸ Deep tendon reflex grading (0-4+), posturing (decorticate/decerebrate), and neurological disorders are testable content.
▸ Stroke recognition using BE FAST, ischemic vs. hemorrhagic stroke differentiation, and emergency treatment are critical
knowledge areas.
▸ Correct answers and clinical rationales appear below each question for NCLEX board review purposes.
▸ All content reflects current AHA/ASA stroke guidelines and evidence-based neurological assessment standards.
SECTION I — GLASGOW COMA SCALE (GCS): EYE, VERBAL & MOTOR Questions 1 –
RESPONSES 15
1. GCS eyes score 4 indicates what response?
A. Response to pain
B. Response to speech
C. Spontaneous response — eyes open spontaneously without any stimulus
D. No response
CORRECT ANSWER C — Spontaneous response; eyes open spontaneously without any stimulus; best possible eye
response
RATIONALE A GCS eye score of 4 is the maximum score for eye opening — the patient opens their eyes spontaneously
without any external stimulus. This indicates intact function of the reticular activating system in the
brainstem, which controls arousal and wakefulness. Spontaneous eye opening means the patient is awake
and aware, though they may not be fully oriented. The eye response component of the GCS ranges from 1 (no
eye opening) to 4 (spontaneous). Scores of 3 (to speech), 2 (to pain), and 1 (none) indicate progressively
decreasing levels of consciousness and more severe brain dysfunction. The full GCS (E+V+M) ranges from 3-15.
,2. GCS eyes score 3 indicates what response?
A. Spontaneous response
B. Response to speech (to verbal command) — eyes open when called or spoken to
C. Response to pain
D. No response
CORRECT ANSWER B — Response to speech (to verbal command); eyes open when called or spoken to
RATIONALE A GCS eye score of 3 indicates the patient opens their eyes in response to verbal stimuli — when their name is
called or a command is given. This means the patient does NOT spontaneously open their eyes but will do so
when spoken to, indicating the brainstem reticular activating system can be aroused by auditory input. The
nurse should use a normal tone first, then a louder voice if no response. A score of 3 is one level below
spontaneous (4) and indicates a mild decrease in consciousness. If the patient only responds to loud noise or
shouting, this still falls under score 3 — it represents any verbal stimulus. If there is no response to voice but
the patient opens eyes to pain, the score drops to 2.
3. GCS eye score 2 indicates what response?
A. Spontaneous response
B. Response to speech
C. Response to pain — eyes open only to painful stimulus (e.g., sternal rub, nail bed pressure)
D. No response
CORRECT ANSWER C — Response to pain; eyes open only to painful stimulus (e.g., sternal rub, nail bed pressure); no
response to voice
RATIONALE A GCS eye score of 2 indicates the patient opens their eyes ONLY to a painful stimulus — there is no response
to verbal commands or normal speech. Painful stimuli used include sternal rub (rub knuckles firmly on the
sternum), nail bed pressure (apply pressure to the nail bed with a pen), or trapezius pinch. The patient does
NOT spontaneously open eyes and does NOT open eyes when spoken to. A score of 2 indicates significant
depression of consciousness — the brainstem is still responsive to noxious stimuli but not to auditory input. It
is important to apply a standardized painful stimulus and observe for eye opening (not just grimacing or
withdrawal). A score of 1 indicates no response at all.
4. GCS eye score 1 indicates what response?
A. Response to pain
B. Response to speech
C. Spontaneous response
D. No response — no eye opening to any stimulus; indicates severe brain dysfunction
CORRECT ANSWER D — No response; no eye opening to any stimulus; indicates severe brain dysfunction
RATIONALE A GCS eye score of 1 is the lowest possible eye score — the patient does NOT open their eyes to any stimulus,
including spontaneous, verbal, or painful stimuli. This indicates severe depression of the reticular activating
system and brainstem function, which is a grave prognostic sign. It may result from severe traumatic brain
injury, massive stroke, drug overdose, or post-cardiac arrest anoxic brain injury. Importantly, a score of 1 does
NOT necessarily indicate brain death — the patient may still have intact brainstem reflexes (pupillary, corneal,
gag). However, persistent eye score of 1 combined with absent motor and verbal responses (total GCS 3) in
the absence of sedation or neuromuscular blockade is consistent with brain death. All three GCS components
must be assessed together.
, 5. GCS verbal score 5 indicates what response?
A. Confused response
B. Oriented x4 (person, place, time, situation) — best possible verbal response
C. Inappropriate words
D. Incomprehensible sounds
CORRECT ANSWER B — Oriented x4 (person, place, time, situation); best possible verbal response
RATIONALE A GCS verbal score of 5 is the maximum verbal score — the patient is fully oriented to all four domains: Person
(knows their name), Place (knows where they are — hospital, city), Time (knows the date, day, month, year),
and Situation (understands why they are there). This indicates intact cognitive function and cortical
processing. The nurse assesses orientation by asking specific questions: "What is your name? Where are you
right now? What is today's date? Why are you here?" If the patient answers all correctly, they score a 5. If they
are conversant but confused or disoriented (can answer questions but answers are incorrect), the score drops
to 4. The verbal component is a key indicator of higher cortical function and is often the first GCS component
to decline with neurological deterioration.
6. GCS verbal score 4 indicates what response?
A. Oriented x4
B. Confused response — patient responds but is disoriented or confused; can answer questions but answers may be
incorrect
C. Inappropriate words
D. No response
CORRECT ANSWER B — Confused response; patient responds but is disoriented or confused; can answer questions but
answers may be incorrect
RATIONALE A GCS verbal score of 4 indicates the patient is conversant and can produce sentences, but is confused or
disoriented — they answer questions but get them wrong. For example, the patient may know their name but
think they are at home (not the hospital), or give the wrong year, or be unsure why they are there. The key
distinction from score 5 (oriented) is that the answers are incorrect. The patient's speech is fluent and
grammatically correct but the content is confused. This is common in acute confusional states (delirium),
dementia, post-ictal states, and metabolic encephalopathy. A score of 4 represents a mild-to-moderate
cognitive impairment. If the patient uses only random or inappropriate words rather than conversational
sentences, the score drops to 3.
7. GCS verbal response 3 indicates what response?
A. Confused conversation
B. Oriented x4
C. Inappropriate words — patient uses words but they are not appropriate to context; may consist of random or
incomprehensible words
D. No response
CORRECT ANSWER C — Inappropriate words; patient uses words but they are not appropriate to context; may consist of
random or incomprehensible words
RATIONALE A GCS verbal score of 3 indicates the patient produces recognizable words, but they are random,
inappropriate to the situation, or nonsensical — not coherent conversational speech. Examples: the patient
may swear repeatedly, repeat a single word, or produce words that have no relationship to the question
asked. The patient is NOT having a conversation and cannot answer questions meaningfully. This differs from
score 4 (confused conversation) where sentences are formed but content is incorrect, and from score 2
(incomprehensible sounds) where no recognizable words are produced. A score of 3 indicates significant
cortical dysfunction, often seen with severe traumatic brain injury, large stroke, or deep sedation. The nurse
documents exactly what the patient said.
