NUR 390 Exam 3 – Nursing Practice & Clinical Study Guide
what is the Glasgow Coma Scale (GCS)? - (answer)quick, standard system for assessing LOC
what areas are assessed with the GCS? - (answer)1. open eyes with verbal/painful stimulus
2. speak
3. obey commands
what are the indicators of response to opening eyes with verbal/painful stimulus? - (answer)opens eyes
GCS eyes open scores - (answer)4
3
2
1
U
what are the appropriate stimuli for opening eyes? - (answer)approach bedside
verbal command
pain
eyes open: score 4 - (answer)spontaneous response
eyes open: score 3 - (answer)open eyes to name/command
eyes open: score 2 - (answer)only opens eyes to pain
,NUR 390 Exam 3 – Nursing Practice & Clinical Study Guide
eyes open: score 1 - (answer)does not open eyes to any stimulus
eyes open: score U - (answer)untestable
what are the indicators of response to speaking? - (answer)best verbal response
GCS best verbal response scores - (answer)5
4
3
2
1
U
what are the appropriate stimuli for best verbal response? - (answer)verbal questioning with maximal
arousal
best verbal response: score 5 - (answer)appropriate orientation
identifies self, place, year, and month
best verbal response: score 4 - (answer)confused
disoriented in 1 or more areas
best verbal response: score 3 - (answer)inappropriate/disorganized use of words (cursing)
lack of sustain convo
,NUR 390 Exam 3 – Nursing Practice & Clinical Study Guide
best verbal response: score 2 - (answer)incomprehensible words/sounds
(moaning)
best verbal response: score 1 - (answer)lack of sound even with painful stimuli
best verbal response: score U - (answer)untestable
what are the indicators of response for obeying commands? - (answer)best motor response
GCS best motor response scores - (answer)6
5
4
3
2
1
U
what are the appropriate stimuli for best motor response? - (answer)verbal command
pain
example of verbal command for best motor response - (answer)"raise your arm"
"hold up 2 fingers"
example of pain for best motor response - (answer)pressure on proximal nail bed
, NUR 390 Exam 3 – Nursing Practice & Clinical Study Guide
best motor response: score 6 - (answer)obeys command
best motor response: score 5 - (answer)localizes pain but lack of obedience
attempts to remove pain stimulus
best motor response: score 4 - (answer)flexion withdrawal
best motor response: score 3 - (answer)abnormal flexion
best motor response: score 2 - (answer)abnormal extension
best motor response: score 1 - (answer)lack of resposne
best motor response: score U - (answer)untestable
what is the lowest possible GCS score? - (answer)3
(deep coma or death)
what is the highest possible GCS score? - (answer)15
(fully alert)
a GCS score of ____ or less generally indicates coma and _____ may be necessary - (answer)8;
mechanical ventilation
what is the Glasgow Coma Scale (GCS)? - (answer)quick, standard system for assessing LOC
what areas are assessed with the GCS? - (answer)1. open eyes with verbal/painful stimulus
2. speak
3. obey commands
what are the indicators of response to opening eyes with verbal/painful stimulus? - (answer)opens eyes
GCS eyes open scores - (answer)4
3
2
1
U
what are the appropriate stimuli for opening eyes? - (answer)approach bedside
verbal command
pain
eyes open: score 4 - (answer)spontaneous response
eyes open: score 3 - (answer)open eyes to name/command
eyes open: score 2 - (answer)only opens eyes to pain
,NUR 390 Exam 3 – Nursing Practice & Clinical Study Guide
eyes open: score 1 - (answer)does not open eyes to any stimulus
eyes open: score U - (answer)untestable
what are the indicators of response to speaking? - (answer)best verbal response
GCS best verbal response scores - (answer)5
4
3
2
1
U
what are the appropriate stimuli for best verbal response? - (answer)verbal questioning with maximal
arousal
best verbal response: score 5 - (answer)appropriate orientation
identifies self, place, year, and month
best verbal response: score 4 - (answer)confused
disoriented in 1 or more areas
best verbal response: score 3 - (answer)inappropriate/disorganized use of words (cursing)
lack of sustain convo
,NUR 390 Exam 3 – Nursing Practice & Clinical Study Guide
best verbal response: score 2 - (answer)incomprehensible words/sounds
(moaning)
best verbal response: score 1 - (answer)lack of sound even with painful stimuli
best verbal response: score U - (answer)untestable
what are the indicators of response for obeying commands? - (answer)best motor response
GCS best motor response scores - (answer)6
5
4
3
2
1
U
what are the appropriate stimuli for best motor response? - (answer)verbal command
pain
example of verbal command for best motor response - (answer)"raise your arm"
"hold up 2 fingers"
example of pain for best motor response - (answer)pressure on proximal nail bed
, NUR 390 Exam 3 – Nursing Practice & Clinical Study Guide
best motor response: score 6 - (answer)obeys command
best motor response: score 5 - (answer)localizes pain but lack of obedience
attempts to remove pain stimulus
best motor response: score 4 - (answer)flexion withdrawal
best motor response: score 3 - (answer)abnormal flexion
best motor response: score 2 - (answer)abnormal extension
best motor response: score 1 - (answer)lack of resposne
best motor response: score U - (answer)untestable
what is the lowest possible GCS score? - (answer)3
(deep coma or death)
what is the highest possible GCS score? - (answer)15
(fully alert)
a GCS score of ____ or less generally indicates coma and _____ may be necessary - (answer)8;
mechanical ventilation
