Reduction of Risk Potential

36. The neurological assessment of a client diagnosed with a ruptured cerebral aneurysm reveals the client is unresponsive to verbal stimuli, occasionally moans and, when painful stimuli are applied, decerebrate posturing and partial eye openings are noted. A nurse assesses that this client should receive of score of _______ on the Glasgow Coma Scale (GCS).

Choices

Question  Hint

Test-Taking Tip

Normal response is 15 and no response is 3. The GCS is used to evaluate ability to open eyes, respond verbally, and move normally, primarily in clients with trauma or stroke.

Content Area: Adult Health, Neurological; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Diagnostic Tests

Go to Choices

Reduction of Risk Potential

6

Using the GCS, this client receives 2 points for opening eyes to painful stimuli, 2 points for extensor posturing, and 2 points for incomprehensible sounds. Total score is 6 out of 15.

Go to Question