Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
5. A 3-year-old child is admitted to an emergency department after being struck by an automobile. A nurse's assessment reveals a child with spontaneous eye opening. The child is confused and does not obey commands but is able to localize pain. The nurse correctly calculates a score of __________ on the Glasgow Coma Scale.
Test-Taking Tip
Remember that the lowest score an individual can receive on the GCS is 3 (no eye opening and no motor nor auditory/visual response) and the highest is 15.
Content Area: Child Health, Neurological; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
13
To arrive at the correct score on the Glasgow Coma Scale (GCS), recall that the scale is composed of three scoring areas: eye opening (ranges from 1 to 4), best motor response (ranges from 1 to 6), and best auditory/visual response (ranges from 1 to 5). This child receives the maximum score of 4 for spontaneous eye opening, a score of 5 out of 6 for motor response, and 4 out of 5 for auditory/visual response.