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. The patient demonstrates Flight of ideas B. demonstrates confabulation C. depressed D. demonstrates schizophrenia

Correct Answer is A

Explanation

A. Flight of ideas is characterized by a rapid and continuous flow of thoughts where the individual frequently shifts topics, often making it difficult to follow their conversation. This is commonly observed in conditions like mania or hypomania, often seen in bipolar disorder.
B. Confabulation involves fabricating or inventing stories or information to fill in gaps in memory. It is often seen in conditions affecting memory or cognition, such as Korsakoff’s syndrome or certain types of dementia.
C. Depression typically involves symptoms such as low mood, decreased energy, and lack of interest in activities, rather than rapid speech or topic shifts. The client’s accelerated pace of speech and jumping from topic to topic do not align with the characteristics of depression.
D. Schizophrenia is a broad term for a range of symptoms, including hallucinations, delusions, disorganized thinking, and impaired social functioning. While disorganized thinking can be a symptom of schizophrenia, the specific behavior described (accelerated speech and jumping topics) more specifically indicates flight of ideas, which is not exclusive to schizophrenia.

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

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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

The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic no of which progresses to sensible conversation. What would the nurse document about this client?

Correct Answer is A

Explanation

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

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?

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

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:

When preparing to test a client for meningeal irritation, what would the nurse do first?

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 client is able to actively move the right arm against gravity. How should the nurse document this finding using the muscle strength grading?

In the Neuro ICU, a comatose patient has this posture in bed: Upper arms are flexed tight to the sides with elbows, wrists, and fingers flexed. The legs are extended and internally rotated. The nurse interprets this posture as: