Practice Question
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye-opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?
Answer Choices:
Correct Answer:
The client can follow simple motor commands.
Rationale:
✍️ A GCS score is calculated as:
▪ Eye opening = 3 (to verbal command)
▪ Verbal = 5 (oriented and converses normally)
▪ Motor = 5 (localizes pain or follows simple commands)
✍️ Total score = 13, indicating mild brain injury, not unconsciousness.
✍️ Since the motor response is 5, the client can follow commands, which helps assess neurological function.
✍️ Eye opening to voice (not spontaneously) also supports the conclusion that the client is responsive and aware.
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This question is from RN ATI Custom Medical Surgical Nurs Exam 2 which contains 46 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI MedSurg
- Answer Choices: 4
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