Components of the Glasgow Coma Scale (GCS) the nurse would use to ...

[KimWrice]

Components of the Glasgow Coma Scale (GCS) the nurse would use to assess a patient after a head injury include which assessment?
 
  a. Blood pressure
  b. Cranial nerve function
  c. Head circumference
  d. Verbal responsiveness

Question 2

Which assessment finding would be the earliest and most sensitive indicator that there is an alteration in intracranial regulation?
 
  a. Change in level of consciousness
  b. Inability to focus visually
  c. Loss of primitive reflexes
  d. Unequal pupil size

[LP]

Answer to Question 1

ANS: D
Components of the GCS include eye opening, motor responsiveness, and verbal responsiveness. The nurse would want to assess the blood pressure, but this is not a component of the coma scale. Assessment of cranial nerve function is appropriate as alterations such as cranial nerve VI palsies may occur, but this is not part of the coma scale. Increases in head circumference are associated with alterations in intracranial pressure in infants, but this is not part of the coma scale.

Answer to Question 2

ANS: A
A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refer to those reflexes found in a normal infant that disappear with maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS.

[KimWrice]

TYSM

[ryhom]

Excellent