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. Cranial nerve V (trigeminal) is not directly related to ataxia or balance. It is more involved in sensory perception of the face and motor function for chewing.
B. Kernig's sign is a test for meningitis, not ataxia or balance issues. It involves flexing the hips and knees to check for resistance or pain that may suggest meningeal irritation.
C. Clubbing is related to chronic oxygenation issues or respiratory/cardiovascular conditions, but it is not a direct assessment of ataxia or balance.
D. A Romberg's test is used to assess balance and proprioception. By having the client stand with feet together and eyes closed, the nurse can assess the client's ability to maintain balance and identify any unsteadiness or ataxia that may impair safe ambulation.
Correct Answer is C
Explanation
A. Confluent lesions merge together, forming a larger area of affected skin, which is not the case here.
B. Discrete lesions are separate and distinct from each other, which doesn't match the description of clusters.
C. Grouped lesions are those that appear in clusters, which fits the assessment finding.
D. Annular lesions have a ring-like appearance, typically seen in conditions like ringworm, and do not fit the description of clustered lesions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
