One-Minute Nurse: Glasgow Coma Scale: Quiz

What is the highest score a patient can achieve in the Glasgow Coma Scale (GCS)? 5 10 15 20

15 Rationale: Eyes can score up to 4 points, verbal up to 5 points, and motor up to 6 points for a total of a 15-point maximum on the GCS.

How many points will a patient receive for spontaneous eye opening on the Glasgow Coma Scale (GCS)? 1 2 3 4

4 Rationale: The patient who spontaneously opens their eyes receives 4 points for spontaneous eye opening, meaning they can open their eyes without direction. They will get 3 points for opening their eyes in response to speech, 2 points for opening their eyes in response to painful stimuli, and 1 point for no eye opening.

What is the Glasgow Coma Scale (GCS) used to assess?

Level of consciousness Rationale: The GCS is used to assess the level of consciousness. It does not address pulses, arrhythmias, or strength.

A patient scored 4 points for verbal response on the Glasgow Coma Scale (GCS). What does that indicate? The patient is oriented. The patient is confused. The patient is saying inappropriate words. The patient has no verbal response.

The patient is confused. Rationale: If the patient is fully oriented, they get 5 points. If they are confused but speaking coherently, they get 4 points. If the patient is saying inappropriate words and jumbled phrases, they'll get 3 points. Incomprehensible sounds scores 2 points, and 1 point is assigned for no verbal response.

What is the best description decorticate posturing? The patient withdraws into their core. The patient extends their arms away from the body. The patient withdraws from pain. This indicates no response to pain.

The patient withdraws into their core. Rationale: Decorticate posturing is when the patient withdraws into their core. Decerebrate is when the arms extend away from the body.