What is included when the nurse performs the Glasgow Coma Score (GCS) on a client?

Vocalization, strength, and pupillary response and accommodation

Eye opening. verbal response, and motor response

Pupillary reaction, eye opening, and motor response

Motor response. sensory response, and level of consciousness

Answer and Explanation

The Correct Answer is B

A. Vocalization, strength, and pupillary response and accommodation are not components of GCS. Strength testing is part of a motor exam, and pupillary response is part of a cranial nerve assessment.

B. Eye opening, verbal response, and motor response are the three components of the Glasgow Coma Scale (GCS), which assesses a client’s neurological status and level of consciousness.

C. Pupillary reaction, eye opening, and motor response is incorrect because pupillary reaction is not a component of the GCS.

D. Motor response, sensory response, and level of consciousness is incorrect because sensory response is not a part of the GCS.

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Correct Answer is B

Explanation

A. Inspect muscle symmetry in the upper and lower extremities
While muscle symmetry is important, it only assesses muscle mass and atrophy, not motor function or coordination.

B. The RN asks the client to squeeze their hand or show 2 fingers and lift their arm off the bed
This assesses motor strength and coordination, which are key components of motor ability. Handgrip strength and upper limb movement provide important information about neurological function.

C. Check plantar response and deep tendon reflex testing bilaterally
These tests assess reflexes and neurological pathways rather than motor function and coordination.

D. Comparative cranial nerve assessments and ability to follow simple commands
While following commands assesses cognition, it does not directly evaluate muscle strength or motor ability.

A. Control dysrhythmias and decrease the heart rate B. Decrease cardiac workload and increase systemic perfusion C. Improve oxygen exchange and decrease urinary output D. Decrease the blood pressure and respiratory rate

Correct Answer is B

Explanation

A. Control dysrhythmias and decrease the heart rate

Controlling dysrhythmias is important, but decreasing heart rate is not always the goal, as a compensatory tachycardia may be necessary for perfusion.

B. Decrease cardiac workload and increase systemic perfusion

Cardiogenic shock results from impaired cardiac output. The goal is to reduce the heart’s workload (e.g., by reducing afterload) while improving systemic perfusion.

C. Improve oxygen exchange and decrease urinary output

Oxygenation is important, but decreased urinary output indicates poor renal perfusion and worsening shock, which is not a goal of treatment.

D. Decrease the blood pressure and respiratory rate

In cardiogenic shock, blood pressure is already low. The goal is to maintain adequate perfusion, not to further reduce BP.

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What is included when the nurse performs the Glasgow Coma Score (GCS) on a client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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