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

1. A

   Can follow simple commands

2. B

   Will make no attempt to vocalize

3. C

   Is unconscious

4. D

   Is able to open his eyes when spoken to

Appeared in: AIIMS Delhi NO - 2018

Explanation

• A Glasgow Coma Scale (GCS) score of 4 falls within the range of 3-8, which defines a comatose state.
• Coma is a state of profound unconsciousness where the patient cannot be aroused.
• A patient with a GCS of 4 will not be able to open their eyes to speech, follow commands, or speak coherently, which are all characteristics of being unconscious.
• The lowest possible GCS score is 3 (no response in any category), and a score of 4 is only one step above this, indicating a very severe level of impairment.

Why Other Options Were Wrong

• Option A: Following simple commands corresponds to a motor response score of 6. A patient with a total GCS of 4 cannot have a motor score of 6.
• Option B: While a patient with a GCS of 4 might make no attempt to vocalize (Verbal score = 1), it's also possible for them to make incomprehensible sounds (Verbal score = 2). Therefore, stating they will make no attempt is not definitively correct for all combinations that result in a score of 4. The term 'unconscious' is a more accurate and encompassing description of their overall state.
• Option D: Opening eyes when spoken to corresponds to an eye-opening score of 3. A patient with a total GCS of 4 cannot achieve this, as the highest possible eye-opening score would be 2 (to pain), and that would require a score of 1 in both verbal and motor categories.

Related Visual

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 fundamental nursing assessment for any patient with a known or suspected brain injury. It provides an objective measure of neurological status and allows for consistent communication among the healthcare team.
• A GCS score of 8 or less is a critical finding. It often serves as a key indicator for the need for advanced airway management (intubation) to protect the airway, as the patient's protective reflexes are likely impaired.
• Nurses perform serial GCS assessments to monitor for improvement or deterioration. A drop in the GCS score is a neurological emergency that must be reported to the physician immediately.

How to Approach the Question

• First, identify the core clinical value provided in the question: a Glasgow Coma Scale (GCS) score of 4.
• Recall the definition and ranges of the GCS. Remember that the scale ranges from 3 (deep coma/death) to 15 (fully awake). A score of 8 or less indicates a severe head injury and coma.
• Place the given score (4) within this range. A score of 4 clearly falls into the 'severe injury/coma' category.
• Evaluate each option based on this understanding. 'Is unconscious' is the definition of a comatose state.
• Eliminate options that describe higher levels of function. Following commands (Motor=6) or opening eyes to speech (Eyes=3) are impossible for a patient with a total score of 4.
• Consider the most accurate and comprehensive option. While 'no vocalization' might be part of the score, 'unconscious' describes the patient's entire clinical state, making it the best answer.

Concept Tested & Keywords

• Concept Tested: Interpretation of Glasgow Coma Scale (GCS) score
• Stem keywords: Glasgow Coma Scale, GCS score of 4, head injury, automobile accident
• Lead-in keywords: understanding of this test
• Clinical cues: GCS of 4: This value is the primary clinical data point, indicating a severe neurological impairment.

Question ID

QBnO0alt00g2Q7CBL_500P

Copy ID

Reference Book

E6 Guide to Mental Health & PSYCHIATRIC NURSING R Sreevani— Part 2 (pp 290-564 of 579) p. 196-198

E6 Nursing Fundamentals Taylor p. 412-414