Glasgow Coma Scale

Category Score Criteria

Eye Opening	4 3 2 1	Spontaneous To Verbal Stimuli To Pain No Response
Verbal Response	5 4 3 2 1	Oriented to time, place, person: uses appropriate words and phrases Confused Inappropriate words or verbal response Incomprehensible words No response
Motor Response	6 5 4 3 2 1	Obeys commands Localizes pain Withdraws to pain Flexion to pain (decorticate) Extension to pain (decerebrate) No response

The nurse is reassessing the level of consciousness in a client with a head Injury and elevated intracranial pressure. The previous Glasgow Coma Scale score was 6. Using the Glasgow Coma Scale, the nurse notes that the client opens the eyes only as a response to pain, responds with sounds that are not understandable, and has abnormal extension of the upper extremities when pain is elicited. What should the nurse do?

A. Ability to self-feed with the use of adaptive equipment: A complete spinal cord transection at the C5 level preserves shoulder function and elbow flexion due to intact innervation of the deltoid and biceps muscles. Although wrist and hand function are typically absent, adaptive devices such as universal cuffs can allow the client to feed independently.

B. Ability to achieve independent transfer from bed to wheelchair: Independent transfers require strong upper extremity function, particularly triceps extension and wrist stability, which are typically intact at C7 or below. With a C5 injury, triceps function is absent, significantly limiting the ability to bear weight through the arms for safe independent transfers.

C. Independent control of bowel and bladder function: A complete spinal cord injury above the sacral segments disrupts voluntary control of bowel and bladder function. Although reflex (spastic) bladder and bowel activity may occur, conscious control is lost. Management usually involves scheduled toileting programs and catheterization rather than independent control.

D. Use of a wheelchair with a chin or mouth stick: Chin or mouth stick controls are typically required for clients with higher cervical injuries, such as C1–C4, where upper extremity movement is absent. At the C5 level, the client retains some shoulder and elbow function, allowing use of a powered wheelchair with hand controls or limited manual mobility.

A. Diverticulitis: Diverticulitis typically presents in older adults with left lower quadrant abdominal pain, fever, and sometimes changes in bowel habits. While diarrhea can occur, chronic bloody stools and systemic symptoms like weight loss are not characteristic. Extraintestinal manifestations such as joint pain are uncommon in diverticulitis.

B. Colon cancer: Colon cancer may cause changes in bowel habits, occult bleeding, and weight loss, but it is less common in young adults and usually does not present with recurrent diarrhea, fecal urgency, or widespread joint pain. The combination of bloody stools and systemic inflammatory symptoms points to an inflammatory bowel disease rather than malignancy.

C. Ulcerative Colitis: Ulcerative colitis typically presents with bloody diarrhea, fecal urgency, cramping abdominal pain (commonly in the left lower quadrant), and weight loss. Extraintestinal manifestations, including arthritis affecting large joints such as elbows and knees, are common. The client’s age, symptom pattern, and joint involvement strongly support ulcerative colitis.

D. Crohn Disease: Crohn’s disease can cause diarrhea, abdominal pain, weight loss, and extraintestinal symptoms. However, Crohn’s often involves the terminal ileum and presents with patchy, transmural inflammation. Bloody diarrhea is less prominent than in ulcerative colitis, and pain is more often right-sided or diffuse rather than strictly left lower quadrant.