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?

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Assess risk for immediate harm should be the priority. The nurse needs to evaluate whether the client is in immediate danger and take the necessary steps to ensure their safety.
B. Instructing the client on how to leave the relationship is important, but the priority is to assess if the client is in immediate danger first.
C. Implementing a safety plan is essential, but first, the nurse must assess the immediate risks to the client's safety.
D. Referring the client to a community support group is a supportive action but should follow the priority steps of ensuring safety and assessing immediate harm.

A. Electrical cords are placed along the walls. B. Scatter rugs are present in the kitchen. C. Handrails are present in the bathroom. D. Uses a microwave for cooking.

Correct Answer is B

Explanation

A. Electrical cords along the walls are not a major safety hazard for individuals with visual impairments as long as they are properly secured and out of the way.
B. Scatter rugs in the kitchen can be a significant risk for falls, especially for individuals with decreased vision. Rugs can cause tripping, and if not secured properly, they can be dangerous in areas with high foot traffic like the kitchen.
C. Handrails in the bathroom are actually a safety feature and would help prevent falls in an area with higher risk of slips.
D. Using a microwave for cooking is a safe alternative to using a stove or oven, especially for someone with visual impairment. It is less hazardous since there is no open flame.

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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?

Nursing Test Bank

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