The nurse is performing a neurologic assessment of a 41-year-old patient the patient is able to open eyes to pain, uses inappropriate words, and has flexion withdrawal from pain. What is their GCS score?
9
7
5
12
The Correct Answer is A
The Glasgow Coma Scale (GCS) measures three aspects: Eye response, verbal response, and motor response.
Eye response: Opens eyes to pain (score 2).
Verbal response: Uses inappropriate words (score 3). Motor response: Flexion withdrawal from pain (score 4). Total GCS = 2 (eyes) + 3 (verbal) + 4 (motor) = 9.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Testing visual acuity: This assesses cranial nerve II (optic), not cranial nerve III.
B. Eliciting the gag reflex: This assesses cranial nerve IX and X (glossopharyngeal and vagus), not cranial nerve III.
C. Observing for facial symmetry: This assesses cranial nerve VII (facial nerve), not cranial nerve III.
D. Checking the pupillary response to light: Cranial nerve III (oculomotor) is responsible for controlling pupil constriction in response to light, making this the correct method to assess cranial nerve III.
Correct Answer is D
Explanation
A. Tilting the head forward is not necessary for the otoscope exam.
B. Pulling the pinna up and back is used for older children and adults.
C. Releasing the pinna after inserting the speculum is unnecessary.
D. For young children under 3 years, the pinna should be pulled down and back to straighten the ear canal.
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