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 D

Explanation

A. The trigeminal nerve (CN V) is primarily responsible for sensation in the face and the motor control of the muscles used for chewing. It does not have a role in balance or equilibrium, so it would not be the focus when assessing balance issues.
B. The facial nerve (CN VII) controls the muscles of facial expression and provides taste sensation to the anterior two-thirds of the tongue. While it plays a significant role in facial movement and taste, it is not involved in balance or equilibrium.
C. The olfactory nerve (CN I) is responsible for the sense of smell. It does not have any role in balance or equilibrium. Balance issues are not related to the olfactory nerve, so this is not the appropriate focus for balance assessment.
D. The vestibulocochlear nerve (CN VIII) has two major components: the cochlear nerve, which is responsible for hearing, and the vestibular nerve, which is responsible for balance and equilibrium. The vestibular component of CN VIII is crucial for maintaining balance and spatial orientation. When a client reports spontaneous loss of balance, this nerve should be the focus of additional assessment.

A. Obturator sign B. Brudzinski sign C. Phalen sign D. Tinel sign

Correct Answer is B

Explanation

A. The obturator sign is used to assess for appendicitis, not meningitis. To perform this test, the patient’s right knee is flexed to 90 degrees, and the nurse rotates the hip internally and externally. Pain during this maneuver can indicate irritation of the obturator muscle, which is associated with inflammation of the appendix.

B. The Brudzinski sign is a clinical test used to assess meningeal irritation. When the patient’s neck is passively flexed while lying supine, a positive Brudzinski sign is indicated if the patient involuntarily flexes their knees and hips in response to neck pain. This sign is often seen in meningitis as a result of irritation of the meninges.
C. The Phalen sign is used to diagnose carpal tunnel syndrome. The patient flexes their wrists and holds the position for a period of time to see if symptoms of numbness or tingling appear in the fingers, which would indicate median nerve compression at the wrist. This sign is unrelated to meningitis.
D. The Tinel sign is also used to diagnose carpal tunnel syndrome and other peripheral nerve issues. It involves tapping on the nerve (such as the median nerve at the wrist) to see if it causes tingling or a “pins and needles” sensation along the nerve’s distribution. Like the Phalen sign, it is not related to meningitis.

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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

During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?

Correct Answer is D

Explanation

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:

Correct Answer is B

Explanation

When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding?

Which of the following would the nurse most likely expect to find when assessing a client diagnosed with a frontal lobe contusion (in the Broca's Area) following a motor vehicle accident?

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A client is clenching the jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve?

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

Stroke Warning signs includes? Select all that applied.