Exam 2 Apply your knowledge Flashcards
whenever you walk into your patients room and they immediately open their eyes, how many points would they score on the eye section of GCS?
4
whenever you walk into your patients room they only open their eyes when you speak to them, how many points would they score on the eye section of GCS?
3
whenever you walk into your patients room your pt only opens their eyes when you tap them on the shoulder, how many points would they score on on the eye section of GCS?
2
whenever you walk into your patients room they never open their eyes, how many points would they score on the eye section of GCS?
1
if your patient got into a accident and suffered blunt force facial trauma that made their eyelids swollen shut, how many points would they score on the eye response section of the GCS?
not testable
if a patient speaks appropriately whenever communicating, what would they score on the verbal response of GCS?
5
you are assessing a patients ANO status, when you ask them what year it is, they respond with 1989, what would they score on the verbal response of GCS?
4
you are speaking to a patient and you ask them how are you? and they respond with “apple skipping down a road yesterday.” what would you score them on verbal response of GCS?
3
you are speaking to a patient and whenever they respond to something its always inaudible sounds that dont make out any actual words. What would you score them on the verbal response of GCS?
2
if you are speaking to a patient and they never give you a verbal response, what would you score them on the verbal response of GCS?
1
if you are assessing a patient using GCS and you are trying to assess the verbal response and the patient is intubated, what would you score the pt?
not testable
to test your patients response to central stimuli, where can you create pain?
sternal rub, trapezius squeeze, supraorbital pressure
to test your patients response to peripheral stimuli, where can you create pain?
pressure on nail bed
you ask you patient to squeeze your hands and they consensually squeeze your hands hard, what score would they get on motor response GCS?
6
you conduct a trapezius squeeze on your patient and they grab your arm and bring it down to stop the pain, what would they score on the motor response of GCS?
5
you conduct a trapezius squeeze and your patients response is to flex the elbow joint then put it back down, what score would they score on the motor response of GCS?
4
you conduct a trapezius squeeze and your patients response is to flex the elbow joint, create a fist, and bring his arm towards his chest and it stays there, what score would they score on the motor response of GCS?
3
you conduct a trapezius squeeze and your patients response is to extend their arm while its still flat and it stays there, what score would they score on the motor response of GCS?
2
you apply painful stimulus to see pts response and there is no response, what would you rate their motor response on GCS?
1
You’re assessing a patient’s Glasgow Coma Scale at the bedside. What is the patient’s score based on these findings: when you arrive to the patient’s bedside the patient’s eyes are closed, but they open when you speak to the patient, the patient doesn’t respond appropriately to questions asked and says words that don’t make sense. In addition, the patient can’t obey a motor command. Therefore, when you apply a central stimulus the patient moves to locate and remove the stimulus.
A. GCS 12 (E3 V4 M5)
B. GCS 8 (E2 V4 M2)
C. GCS 11 (E3 V3 M5)
D. GCS 10 (E3 V3 M4)
C: GCS 11 (E3 V3 M5)
You’re assessing a patient’s Glasgow Coma Scale at the bedside. What is the patient’s score based on these findings: when you arrive to the patient’s bedside the patient’s eyes are closed but they open when you speak to the patient. The nurse cannot assess best verbal response because the patient is intubated. In addition, the patient can’t obey a motor command. Therefore, when you apply a central stimulus the patient flexes to withdraw from the stimulus.
A. GCS 8 (E3 V1 M4)
B. GCS 7T (E3 Vt M4)
C. GCS 9 (E3 V1 M5)
D. GCS 6T (E3 Vt M3)
B. GCS 7T (E3 Vt M4)
You’re assessing a patient’s Glasgow Coma Scale at the bedside. What is the patient’s score based on these findings: when you arrive to the patient’s bedside the patient’s eyes are closed and don’t open when spoken to. The nurse applies a peripheral painful stimulus, and the patient’s eyes open. When asked questions the patient groans and moans noises. In addition, the patient can’t obey a motor command. Therefore, when you apply a central stimulus the patient flexes to withdraw from the stimulus.
A. GCS 12 (E3 V4 M5)
B. GCS 8 (E2 V4 M2)
C. GCS 8 (E2 V2 M4)
D. GCS 10 (E3 V3 M4)
C. GCS 8 (E2 V2 M4)
The Glasgow Coma Scale (GCS) assesses what areas of response to stimuli? Select all that apply:
A. Auditory response
B. Verbal response
C. Tactile response
D. Eye-opening response
E. Motor response
B,D,E
An 86 year old female patient is immobile and is in the right lateral recumbent position. As the nurse you know that which sites below are at most risk for pressure injury in this position?
A. Sacral
B. Patella
C. Ankle
D. Ear
E. Elbow
F. Hip
G. Heel
H. Shoulder
B,C,D,F,H
