A patient with head injury came in emergency department, initial assessment of patient was eye opening with painful stimuli, repetitive movements with withdrawal from pain and lethargic and confused. What would be maximum score of GCS assessed by nurse?

1. A

   15

2. B

   10

3. C

   8

4. D

   6

Appeared in: NORCET 3 - 2022 (Shift-2)

Explanation

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• The Glasgow Coma Scale (GCS) is calculated by summing the scores from three categories: Eye Opening, Verbal Response, and Motor Response.
• In this scenario, the patient's Eye Opening is to painful stimuli, which scores 2 points (E2).
• The Verbal Response is confused, which scores 4 points (V4).
• The Motor Response is withdrawal from a painful stimulus, which scores 4 points (M4).
• The total GCS score is the sum of these individual scores: E2 + V4 + M4 = 10.
• A total score of 10 indicates a moderate head injury, requiring diligent nursing assessment and monitoring.

Why Other Options Were Wrong

• Option A: A score of 15 is the maximum possible GCS score, representing a fully awake, alert, and oriented patient (E4V5M6). This patient is confused and only responds to pain, making a score of 15 incorrect.
• Option C: A score of 8 or less indicates a severe head injury and a comatose state. This patient's ability to have a confused conversation (V4) places them above this critical threshold.
• Option D: A score of 6 would represent a more severe neurological impairment. This is inconsistent with the patient's presentation of being confused and withdrawing from pain.

Related Visual

• Visual 1: Chart - A detailed chart of the Glasgow Coma Scale, showing all possible responses and their corresponding scores for Eye, Verbal, and Motor components.
• Visual 2: Infographic - An infographic illustrating the classification of traumatic brain injury severity (Mild, Moderate, Severe) based on the total GCS score.

Clinical Relevance

• Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Glasgow Coma Scale (GCS) Assessment in acute care settings.
• The GCS is a critical, standardized tool for objectively assessing a patient's level of consciousness. It facilitates clear communication between healthcare providers about a patient's neurological status and trends.
• Nurses must perform serial GCS assessments because a drop in the score (especially by 2 or more points) is a key indicator of neurological deterioration and requires immediate escalation to the medical team.
• A GCS score of 8 or less is a critical finding and is a common indication for endotracheal intubation to protect the airway.

How to Approach the Question

• First, identify that the question requires you to calculate a Glasgow Coma Scale (GCS) score from a clinical scenario.
• Next, systematically evaluate the patient's response in each of the three GCS categories described: Eye Opening, Verbal Response, and Motor Response.
• For Eye Opening, 'eye opening with painful stimuli' corresponds to a score of 2.
• For Verbal Response, 'lethargic and confused' corresponds to a score of 4.
• For Motor Response, 'withdrawal from pain' corresponds to a score of 4.
• Finally, sum the scores from the three categories (2 + 4 + 4) to arrive at the total GCS of 10 and select the matching option.

Concept Tested & Keywords

• Concept Tested: Glasgow Coma Scale (GCS) Assessment
• Stem keywords: head injury, emergency department, GCS, painful stimuli, withdrawal from pain, confused
• Lead-in keywords: maximum score
• Clinical cues: Patient with head injury
• Clinical cues: Eye opening to pain

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QTOtbPH6KAttmBfAltoaTf

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