A nurse in an emergency department is caring for a client following a motor-vehicle crash.
The client’s Glasgow coma scale rating is 15.
Which of the following findings should the nurse expect
A.
The client withdraws from pain
B.
The client is unable to obey commands.
C.
The client opens eyes to sound
D.
The client is oriented times three
The Correct Answer and Explanation is:
The correct answer is:
D. The client is oriented times three.
Explanation:
The Glasgow Coma Scale (GCS) is a tool used to assess the level of consciousness in clients, especially those with head injuries or other conditions affecting brain function. The scale evaluates three key areas: eye opening, verbal response, and motor response. Each area is scored, and the total GCS score ranges from 3 to 15, with 15 representing the highest level of consciousness (fully alert and oriented).
A GCS score of 15 indicates that the client is fully awake, responsive, and able to interact normally with their environment. This level of consciousness is considered normal, with no significant impairments in cognitive or motor functions.
Here’s how the GCS is broken down:
- Eye Opening (E):
- 4: Spontaneous (The client opens their eyes without any stimulation).
- 3: To sound (The client opens their eyes in response to verbal stimuli).
- 2: To pressure (The client opens their eyes in response to pain).
- 1: No eye opening.
- Verbal Response (V):
- 5: Oriented (The client is oriented to person, place, and time).
- 4: Confused (The client is speaking but disoriented).
- 3: Inappropriate words (The client is speaking but inappropriately).
- 2: Incomprehensible sounds.
- 1: No verbal response.
- Motor Response (M):
- 6: Obeys commands (The client can follow simple commands).
- 5: Localizes to pain (The client moves their body purposefully in response to pain).
- 4: Withdraws from pain.
- 3: Abnormal flexion to pain (Decorticate posturing).
- 2: Abnormal extension to pain (Decerebrate posturing).
- 1: No motor response.
In this case, the client has a GCS of 15, meaning they:
- Open their eyes spontaneously (score of 4),
- Are fully oriented to person, place, and time (score of 5),
- Can obey commands (score of 6).
This combination results in a total GCS of 15, indicating that the client is awake, alert, and oriented. Therefore, D. The client is oriented times three is the correct expectation.
Options A, B, and C describe behaviors that would result in lower GCS scores:
- A. Withdraws from pain would be a motor response score of 4, lowering the GCS.
- B. Unable to obey commands would lower the motor response score below 6.
- C. Opens eyes to sound would give a score of 3 for eye opening, also lowering the total score.
Thus, the expectation for a GCS of 15 is a fully oriented and responsive client.