Which are the 3 areas included in the Glasgow Coma Scale to assess levels of consciousness? Select all that Apply.

Verbal respond

Motor respond

Pupillary responds

Gag Reflex

Eye Opening

Answer and Explanation

Correct Answer : A,B

A.   The verbal response is one of the three components of the Glasgow Coma Scale. It assesses the patient's ability to speak and respond appropriately to questions, indicating their level of consciousness. Responses are scored based on clarity, coherence, and relevance.
B.   Motor response is another component of the Glasgow Coma Scale. It evaluates the patient’s ability to move in response to stimuli, including purposeful movements, localizing pain, or abnormal posturing. The motor response helps gauge the patient’s level of consciousness and neurological function.
C.   Pupillary response refers to how the pupils react to light and changes in size. While important in neurological assessments, it is not one of the three components of the Glasgow Coma Scale. Pupillary response is assessed separately from the GCS but provides additional information about brain function and potential injury.
D.   The gag reflex is a protective mechanism to prevent choking and is assessed by stimulating the back of the throat. It is not included in the Glasgow Coma Scale. The GCS focuses on eye opening, verbal response, and motor response rather than reflexes.
E.   Eye opening is the third component of the Glasgow Coma Scale. It assesses the patient’s ability to open their eyes spontaneously or in response to stimuli. This component helps determine the level of consciousness and alertness.

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Correct Answer is ["C","D","E"]

Explanation

A. Swallowing involves the muscles of the throat and esophagus rather than the TMJ.
B. Extending the tongue involves the muscles of the tongue and mouth, which are not directly related to the TMJ.
C. Rocking the jaw laterally (side to side) is a specific movement that involves the TMJ. This movement tests the ability of the TMJ to move the jaw from side to side.
D. Opening and closing the mouth involves the primary hinge movement of the TMJ. This movement assesses the vertical range of motion of the jaw.
E. Jutting the jaw forward (protrusion) involves moving the lower jaw forward in relation to the upper jaw. This movement tests the ability of the TMJ to perform anterior movement.

A. Extinction B. Stereognosis C. Proprioception D. Two-point discrimination

Correct Answer is B

Explanation

A. Extinction refers to the phenomenon where a person fails to recognize a stimulus on one side of the body when another stimulus is presented simultaneously on the opposite side. This is often tested in cases of neurological impairment, particularly in the context of sensory neglect or loss
B. Stereognosis is the ability to identify an object by touch and proprioception without visual input. It involves recognizing the shape, size, and texture of an object solely through tactile information. Placing a coin in the patient’s hand and asking them to identify it with their eyes closed tests their ability to use tactile information to recognize objects, making stereognosis the correct term for this assessment.
C. Proprioception is the sense of the position and movement of the body and its parts. It involves awareness of body position in space, which is crucial for coordination and balance. While important, proprioception does not specifically involve identifying objects by touch alone; it is more about the awareness of body position.
D. Two-point discrimination is the ability to distinguish between two closely spaced points of contact on the skin. It tests the sensitivity of the skin to touch and is often used to assess sensory nerve function. It does not involve identifying objects by touch but rather measuring how well one can discern between two separate points of contact.

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Which are the 3 areas included in the Glasgow Coma Scale to assess levels of consciousness? Select all that Apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

The nurse places a coin in the patient's hand, the patient is with eyes closed. The ability to identify an object by feeling it is defined as:

Correct Answer is B

Explanation

The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

A patient is able to move both upper arms as follows: active movement against gravity, and some resistance. The nurse should document the muscle strength of the upper arms as:

A patient is diagnosed with Meningitis. During the physical examination in the supine position, the nurse flexed the patient's neck and the patient flexed his knees and hip while complaining of neck pain. This is known as:

A nurse is performing a physical examination on a patient. When the patient is asked to protrude his tongue, the nurse noticed a deviation from the midline to the right side. This is related to a lesion of:

Taste in the 1/3 posterior of your tongue is given by:

A patient that is Comatose based on the Level of Consciousness (LOC) assessment using the Glasgow Coma scale is in what numeric range of the scale?

During an assessment, the nurse asks a client to explain what the following means: "A penny saved is a penny earned." The nurse is assessing which of the following?