A 35 year old man was in an automobile accident with admitting diagnosis of head injury. He has a Glasgow Coma Scale score of 4. Upon MRI and CT scan, brain tumor was also suspected. He was with another person who had sustained head contusion. The nurse's understanding of this test is that the client?

Appeared in: AIIMS Delhi NO - 2018

Explanation

A Glasgow Coma Scale (GCS) score of 8 or less is the clinical definition of a coma, which indicates a severe head injury.
The patient's score of 4 falls squarely within the severe range (3-8), signifying a state of deep unconsciousness.
The GCS assesses eye, verbal, and motor responses. A total score of 4 represents minimal responsiveness across these critical neurological functions.

Option A: Following simple commands corresponds to a Motor Response score of 6. The minimum possible total GCS to perform this action is 8 (E1+V1+M6), which is significantly higher than the patient's score of 4.
Option B: This is not a guaranteed finding. A GCS of 4 could result from a combination like E1+V2+M1, where V2 represents 'incomprehensible sounds'. In such a case, the patient is vocalizing, making this statement incorrect.
Option D: Opening eyes to a verbal command is an Eye Opening score of 3. The minimum possible total GCS to exhibit this response is 5 (E3+V1+M1), which is higher than the patient's score of 4.

Clinical Relevance

Nursing practice connection: Use the key finding related to Interpretation of Glasgow Coma Scale (GCS) score to guide bedside assessment, documentation, and the next nursing action.
The GCS is a critical tool for nurses to objectively track changes in a patient's level of consciousness and communicate neurological status effectively to the interdisciplinary team.
The priority nursing intervention for any patient with a GCS score of 8 or less is to protect the airway. These patients have impaired protective reflexes (like gag and cough) and are at high risk for aspiration, often requiring intubation and mechanical ventilation.
What if? If the patient's GCS score deteriorated from 4 to 3 (the lowest possible score), it would indicate a worsening neurological status, possibly due to increasing intracranial pressure or brain herniation. The nurse must notify the physician immediately as this is a critical change.

How to Approach the Question

Identify the key clinical data point in the question: The patient has a Glasgow Coma Scale (GCS) score of 4.
Recall the fundamental interpretation of GCS scores. The most critical threshold is that a score of 8 or less indicates a coma or severe brain injury.
Apply this rule to the patient's score. Since 4 is less than 8, the patient is in a coma and is, by definition, unconscious.
Systematically evaluate the distractor options by considering the specific GCS components. For each action described (e.g., 'following commands'), determine the minimum GCS score required.
Eliminate options describing functions that are impossible for a patient with a GCS of 4 (e.g., following commands requires a minimum score of 8).
Select the option that provides the most accurate and encompassing description of the patient's overall neurological state based on the GCS score of 4.

Concept Tested & Keywords

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E6 Nursing Fundamentals Taylor p. 412-414

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 p. 86-88

Practise the full AIIMS Delhi NO - 2018

Attempt every question from this paper in a timed mock, then review the full solution for each one.