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1. A nurse is assessing a client with a brain injury using the Glasgow Coma Scale...

1. A nurse is assessing a client with a brain injury using the Glasgow Coma Scale (GCS). The client does not open their eyes, makes no sounds, and makes no movements. How would the nurse score the client using the GCS?

                a.6

                b. 16

                c. 3

                d. 5

2. A client is fully awake, knows the date, who they are, and where they are. Which charting statement would most accurately reflect this assessment?

                a. Alert; oriented x 3

                b. Alert; fully oriented

                c. Responds to pain; oriented x 3

                d. Respond to verbal stimuli; oriented x 2

3. A nurse is inspecting a client’s eyes. Which assessment should the nurse complete first?

                a. Pupil response to light

                b. Baseline pupil size and shape

                c. Cardinal fields of vision

                d. Administer the Snellen chart

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Answer #1

1. C(3) no eye response no verbal response no motor response. So score is minimum 1+1+1=3

GCS SCALE:

Eye Opening (E)

  • 4 = spontaneous
  • 3 = to sound
  • 2 = to pressure
  • 1 = none
  • NT = not testable

Verbal Response (V)

  • 5 = orientated
  • 4 = confused
  • 3 = words, but not coherent
  • 2 = sounds, but no words
  • 1 = none
  • NT = not testable

Motor Response (M)

  • 6 = obeys command
  • 5 = localizing
  • 4 = normal flexion
  • 3 = abnormal flexion
  • 2 = extension
  • 1 = none
  • NT = not testable

2. A alert and oriented *3

X1 means “oriented to self or person” – patient knows own name, significant others.
X2 means “oriented to person and place” – knows where he/she is. X3 means “oriented to person, place, and time” – knows the date/day.

3. D smell chart

The key to any examination is to be systematic and always perform each element.

1. Visual acuity

  • In the clinic, visual acuity is typically measured at distance. Otherwise, in a consult setting outside of the clinic, it’s measured at near. Don’t forget to have a near card with you
  • 2. Pupils

  • Look for anisocoria. If present, carefully check the pupil size in both well-lit and dark conditions.
  • Check the reactivity of each pupil with a penlight or Finoff transilluminator.
  • Use the swinging flashlight test to look for a relative afferent pupillary defect.
  • 3. Extraocular motility and alignment

  • Have the patient look in the six cardinal positions of gaze. Test with both eyes open to assess versions — repeat monocularly to test ductions. Figure 1 below shows which muscle is tested in each position.
  • Use the cover/uncover test to assess for heterotropias.
  • Intraocular pressure

  • Goldmann applanation tonometry is the gold standard and should be used in the clinic whenever possible.
  • Outside of the clinic, Tono-Pen tonometry is much more practical.
  • If you suspect a ruptured globe, skip this part of the exam.
  • 5. Confrontation visual fields

  • Assess each quadrant monocularly by having the patient count the number of fingers that you hold up. If acuity is particularly poor, have the patient note the presence of a light.
  • Use the colored lid of an eyedrop bottle to define the position of a scotoma more accurately.
  • 6. External examination

  • Look for any ptosis by measuring the margin-to-reflex distance, which is the distance from the corneal light reflex to the margin of the upper lid.
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