Glasgow Coma Scale (GCS) for Nurses: The Ultimate Guide + MCQs for Exam Preparation

Glasgow Coma Scale:

GCS is a standardized neurological assessment tool used to evaluate and quantify the level of consciousness in patients with acute brain injuries or other neurological conditions. It was developed by neurosurgeons Graham Teasdale and Bryan Jennett at the University of Glasgow in 1974.

Elements of GCS:

The eye-opening reaction, the verbal response, and the motor response are three core elements of the Glasgow coma scale. Based on the observed behavior, each component is evaluated independently and given a numerical score. The scores range from 3 to 15, with 3 indicating deep coma and 15 representing full alertness and responsiveness. The eye-opening response assesses the patient's ability to open their eyes spontaneously, in response to verbal stimuli, or in response to painful stimuli. The verbal response evaluates the patient's ability to communicate, ranging from oriented and coherent speech to no verbal response at all. The motor response examines the patient's ability to follow commands and move purposefully, with scores ranging from purposeful movement to no movement at all.

Multiple Choice Questions for the Post of Nursing Officer:

1. What is the highest score a patient can receive for verbal response on the Glasgow Coma Scale?

(A) 4

(B) 5

(D) 3

Ans. (B) 5

2. In the Glasgow Coma Scale, what is the lowest score a patient can have and still be considered to have a mild brain injury?

(A) 10

(B) 8

(D) 15

Ans. (B) 8

3. What is the GCS score of a patient who opens eyes spontaneously, obeys commands, and utters incomprehensible sounds?

(A) 9

(B) 8

(D) 7

Ans. (A) 9

4. Which component of the Glasgow Coma Scale assesses a patient's best motor response?

(A) Verbal Response

(B) Motor Response

(D) Total Response

Ans. (B) Motor Response

5. What is the GCS score of a patient who opens eyes in response to pain, has confused verbal responses, and flexes their arm in response to pain?

(A) 8

(B) 9

(D) 7

Ans. (B) 9

6. What is the GCS score of a patient who has their eyes closed, utters inappropriate words, and withdraws their arm in response to pain?

(A) 7

(B) 8

(D) 6

Ans. (C) 9

7. What is the GCS score of a patient who has their eyes closed, makes incomprehensible sounds, and extends their arms in response to pain?

(A) 5

(B) 6

(D) 8

Ans. (B) 6

8. What is the primary purpose of assessing a patient's Glasgow Coma Scale score?

(A) To determine the patient's age

(B) To monitor blood pressure

(D) To assess respiratory rate

Ans. (C) To evaluate neurological status

9. Which of the following is a critical nursing intervention for a patient with a low Glasgow Coma Scale score?

(A) Administering pain medication

(B) Raising the head side of the bed

(D) Restraining the patient

Ans. (C) Providing frequent neurological assessments

10. When should a nurse reassess a patient's Glasgow Coma Scale score after an initial assessment?

(A) Every hour

(B) Every shift

(D) Every 24 hours

Ans. (A) Every hour

11. What does a decrease in Glasgow Coma Scale score indicate?

(A) Improvement in neurological status

(B) Deterioration in neurological status

(D) Improvement in motor function

Ans. (B) Deterioration in neurological status

12. What is a potential nursing intervention for a patient with a low Glasgow Coma Scale score to prevent pressure ulcers?

(A) Frequent turning and repositioning

(B) Administering diuretics

(D) Administering anticoagulants

Ans. (A) Frequent turning and repositioning

13. What should a nurse do if a patient's GCS score decreases significantly?

(A) Document the change and continue routine care

(B) Notify the neuro doctor immediately

(D) Administer pain medication

Ans. (B) Notify the neuro doctor immediately

14. Which GCS component assesses a patient's ability to follow commands?

(A) Verbal Response

(B) Motor Response

(D) Total Response

Ans. (B) Motor Response

15. In patients with a low GCS score, what is a crucial nursing intervention to prevent aspiration?

(A) Raising the head side of the bed

(B) Providing oral fluids to maintain electrolyte balance

(D) Administering anticoagulants to prevent clotting

Ans. (A) Raising the head side of the bed

16. What is a potential complication for a patient with a high GCS score who is on prolonged bed rest?

(A) Pressure ulcers

(B) Aspiration pneumonia

(D) Hypertension

Ans. (A) Pressure ulcers

17. What is a potential nursing intervention for a patient with a low GCS score who is unable to protect their airway?

(A) Administering analgesics

(B) Providing mechanical ventilation

(D) Encouraging ambulation

Ans. (B) Providing mechanical ventilation

18. In a patient with a low GCS score, what should the nurse prioritize in the immediate care plan?

(A) Administering pain medication

(B) Ensuring airway, breathing, and circulation

(D) Administering antipyretics

Ans. (B) Ensuring airway, breathing, and circulation

19. What is a potential nursing intervention for a patient with a low GCS score to prevent deep vein thrombosis (DVT)?

(A) Administering antibiotics

(B) Applying sequential compression devices

(D) Providing deep tissue massage

Ans. (B) Applying sequential compression devices

20. What is the primary purpose of the Glasgow Coma Scale in the nursing assessment?

(A) To evaluate cardiac function

(B) To assess neurological status

(D) To monitor the respiratory rate

Ans. (B) To assess neurological status

21. In a patient with a low GCS score, what is a potential nursing intervention to promote sensory stimulation?

(A) Administering sedatives

(B) Providing a quiet environment

(D) Restraining the patient

Ans. (B) Providing a quiet environment

22. What is a potential nursing intervention for a patient with a high GCS score to prevent complications related to immobility?

(A) Encouraging range of motion exercises

(B) Administering sedatives

(D) Administering laxatives

Ans. (A) Encouraging range of motion exercises

23. What is the GCS score of a patient who has their eyes closed, makes no verbal response, and withdraws their arm in response to pain?

(A) 4

(B) 5

(D) 7

Ans. (A) 4

24. What is a potential nursing intervention for a patient with a low GCS score who is at risk for urinary retention?

(A) Encouraging fluid intake

(B) Administering diuretics

(D) Administering antacids

Ans. (C) Inserting a urinary catheter

25. What is a potential nursing intervention for a patient with a low GCS score who is at risk for constipation?

(A) Administering laxatives

(B) Restraining the patient

(D) Encouraging immobility

Ans. (A) Administering laxatives

26. What is a potential nursing intervention for a patient with a low GCS score to promote oral hygiene?

(A) Providing mouthwash

(B) Administering anticoagulants

(D) Administering analgesics

Ans. (A) Providing mouthwash

27. What is the GCS score of a patient who opens eyes in response to pain, utters inappropriate words, and extends their arms in response to pain?

(A) 6

(B) 7

(D) 9

Ans. (A) 6

28. What is a potential nursing intervention for a patient with a high GCS score who is at risk for skin breakdown?

(A) Providing frequent skin assessments

(B) Restraining the patient

(D) Encouraging immobility

Ans. (A) Providing frequent skin assessments

29. What is a potential nursing intervention for a patient with a low GCS score to prevent falls?

(A) Using restraints

(B) Providing a cluttered environment

(D) Encouraging wandering

Ans. (C) Ensuring a well-lit room

30. What is a potential nursing intervention for a patient with a low GCS score to promote communication?

(A) Providing a noisy environment

(B) Encouraging family visits

(D) Using simple, clear instructions

Ans. (D) Using simple, clear instructions

31. What is the GCS score of a patient who has their eyes closed, makes incomprehensible sounds, and flexes their arms in response to pain?

(A) 6

(B) 7

(D) 9

Ans. (C) 8

32. What is a potential nursing intervention for a patient with a low GCS score who is at risk for impaired skin integrity?

(A) Providing moisture barriers

(B) Administering anticoagulants

(D) Encouraging immobility

Ans. (A) Providing moisture barriers

33. What is the GCS score of a patient who opens eyes spontaneously, makes incomprehensible sounds, and extends their arms in response to pain?

(A) 5

(B) 6

(D) 8

Ans. (B) 6

34. What is a potential nursing intervention for a patient with a high GCS score who is at risk for aspiration?

(A) Providing thickened liquids

(B) Administering sedatives

(D) Elevating the head of the bed

Ans. (A) Providing thickened liquids

35. What is the GCS score of a patient who opens eyes in response to pain, utters inappropriate words, and withdraws their arms in response to pain?

(A) 6

(B) 7

(D) 9

Ans. (B) 7

36. What is the GCS score of a patient who opens eyes spontaneously, makes inappropriate words, and flexes their arms in response to pain?

(A) 8

(B) 9

(D) 7

Ans. (C) 10

37. What is a potential nursing intervention for a patient with a high GCS score who is at risk for impaired skin integrity?

(A) Providing moisture barriers

(B) Administering anticoagulants

(D) Encouraging immobility

Ans. (A) Providing moisture barriers

38. What is the GCS score of a patient who has their eyes closed, makes incomprehensible sounds, and extends their arms in response to pain?

(A) 6

(B) 7

(D) 9

Ans. (D) 9

39. What is the GCS score of a patient who opens eyes spontaneously, makes incomprehensible sounds, and extends their arms in response to pain?

(A) 5

(B) 6

(D) 8

Ans. (B) 6

40. Who developed the Glasgow Coma Scale (GCS)?

(A) Florence Nightingale

(B) Graham Teasdale and Bryan Jennett

(D) Albert Einstein

Ans. (B) Graham Teasdale and Bryan Jennett

Understanding the Glasgow Coma Scale is non-negotiable for nursing excellence, and we've aimed to make it as clear as possible. Now it's your turn to solidify that knowledge! Did you find the MCQs helpful? Share your scores or any remaining questions in the comments below. For more essential nursing guides and exam preparation materials, just like GMCH Nursing Officer, NORCET, AIIMS Nursing, and DSSSB, don't forget to explore our other resources on Cares Byte.

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Thank you,

Rajendra Singh

GMCH Chandigarh

Cares Byte Nursing