The nurse is assessing a client that experienced a head injury and assigns a Glascow Coma Scale rating of 3. The nurse would correctly note which of the following for this client? Standard Text: Select all that apply
1. No response with eyes with commands
2. No verbal response
3. Pupil response sluggish
4. No motor movement
5. Pupils fixed and dilated
1,2,4
Rationale 1: No response with eyes with commands. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response, and motor response indicate a score of 3 points.
Rationale 2: No verbal response. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response, and motor response indicate a score of 3 points.
Rationale 3: Pupil response sluggish. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response, and motor response indicate a score of 3 points. The lower the score, the more critical the client's condition. A score of 3 indicates the client's condition is grave. Pupil activity is not evaluated using the Glascow Coma Scale.
Rationale 4: No motor movement. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response, and motor response indicate a score of 3 points. The lower the score, the more critical the client's condition. A score of 3 indicates the client's condition is grave.
Rationale 5: Pupils fixed and dilated. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response, and motor response indicate a score of 3 points. The lower the score, the more critical the client's condition. A score of 3 indicates the client's condition is grave. Pupil activity is not evaluated using the Glascow Coma Scale.
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