ASSESSING THE LEVEL OF CONSCIOUSNESS
What is the purpose of assessing the level of consciousness in a patient?
A. To measure blood pressure
B. To assess respiratory rate
C. To evaluate neurological status and detect changes in mental status
D. To administer medication
ANSWER: C
Which scale is commonly used by nurses to assess the level of consciousness?
A. Glasgow Coma Scale (GCS)
B. Visual Analog Scale (VAS)
C. Numeric Pain Rating Scale (NPRS)
D. Modified Rankin Scale (mRS)
ANSWER: A
What components are typically assessed in the Glasgow Coma Scale (GCS)?
A. Blood pressure, heart rate, and respiratory rate
B. Eye opening, verbal response, and motor response
C. Pain intensity, location, and quality
D. Temperature, skin color, and moisture
ANSWER: B
What is the highest score possible on the Glasgow Coma Scale (GCS)?
A. 10
B. 15
C. 20
D. 25
ANSWER: B
Which response is considered the highest score for eye opening on the Glasgow Coma
Scale (GCS)?
A. No response
B. Opens eyes to pain
C. Opens eyes to verbal command
D. Spontaneously opens eyes
ANSWER: D
Which response is considered the highest score for verbal response on the Glasgow
Coma Scale (GCS)?
A. No response
B. Incomprehensible sounds
C. Oriented and converses normally
D. Inappropriate words
ANSWER: C
Which response is considered the highest score for motor response on the Glasgow
Coma Scale (GCS)?
A. No response
B. Decerebrate posturing
C. Localizing to pain
D. Obeys commands
ANSWER: D
What does a lower score on the Glasgow Coma Scale (GCS) indicate?
A. A deeper level of consciousness
B. A higher level of consciousness
C. Hypertension
D. Bradycardia
ANSWER: A
What should be assessed in addition to the Glasgow Coma Scale (GCS) for a
comprehensive evaluation of consciousness?
A. Blood pressure
B. Respiratory rate
C. Pupillary response and other neurological signs
D. Temperature
ANSWER: C
What is the first step in assessing the level of consciousness in a patient?
A. Measure blood pressure
B. Assess eye opening
C. Assess verbal response
D. Introduce yourself to the patient and explain the procedure
ANSWER: D
What should the nurse do if a patient is unresponsive?
A. Ignore the patient
B. Shake the patient vigorously
C. Call for help and assess for signs of life
D. Administer pain medication
ANSWER: C
What should be assessed if a patient's level of consciousness deteriorates
suddenly?
A. Blood pressure
B. Respiratory rate
C. Pupillary response and neurological signs
D. Heart rate
ANSWER: C
How should the nurse assess verbal response in a patient?
A. By pinching the patient
B. By asking the patient to open their eyes
C. By asking the patient questions and evaluating their responses
D. By shining a light into the patient's eyes
ANSWER: C
What should the nurse assess if a patient opens their eyes in response to verbal
stimulation?
A. Blood pressure
B. Respiratory rate
C. Level of eye opening
D. Pupillary response
ANSWER: C
What does a patient's failure to open their eyes indicate on the Glasgow Coma Scale
(GCS)?
A. A deeper level of consciousness
B. A higher level of consciousness
C. Brain death
D. Seizure activity
ANSWER: A
How should the nurse assess motor response in a patient?
A. By asking the patient questions
B. By administering pain stimulation and observing the patient's response
C. By shining a light into the patient's eyes
D. By checking the patient's blood pressure
ANSWER: B
What should be assessed if a patient exhibits abnormal posturing in response to
pain?
A. Blood pressure
B. Respiratory rate
C. Neurological signs such as pupillary response
D. Heart rate
ANSWER: C
What is decerebrate posturing?
A. Flexion and internal rotation of the upper extremities
B. Extension and external rotation of the upper extremities
C. Flexion and internal rotation of the lower extremities
D. Extension and external rotation of the lower extremities
ANSWER: B
What is decorticate posturing?
A. Flexion and internal rotation of the upper extremities
B. Extension and external rotation of the upper extremities
C. Flexion and internal rotation of the lower extremities
D. Extension and external rotation of the lower extremities
ANSWER: A
What should be documented after assessing the level of consciousness?
A. The patient's shoe size
B. The patient's favorite color
C. The findings of the assessment, including GCS score and any abnormal responses
D. The patient's preferred television show
ANSWER: C
