The nurse assesses several clients using the Glasgow Coma Scale. Which scenario best demonstrates a correct application of this scale?

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11ecbb05_ca36_4eb4_b433_31c471a5dfa0_MD0009_00 The Glasgow Coma Scale is used to determine level of consciousness. The nurse follows a standardized assessment to determine the score of the client's eye opening response, verbal response, and ability to obey commands through a motor response. For the best motor response score, the nurse first verbally asks the client to obey a command. If there is no response, the nurse next uses noxious stimuli (eg, nail bed pressure) and records the physical response. If the client tries to remove the painful stimulus, it is recorded as "localizing" or moving toward the pain; whereas if the client retracts from the stimulus, it is recorded as "withdrawal" (Option A). (Option B) To ensure an accurate score in the verbal response category, the nurse must differentiate if the client is confused (eg, answers "1955" when asked the year) or if a client uses inappropriate words. (Option C) To ensure an accurate eye opening score, the nurse must determine whether the client's eyes open spontaneously (eg, no prompting) or if a stimulus (eg, sound, pain) is needed. (Option D) A social, verbal client is not necessarily oriented. The nurse must assess orientation by specifically asking clients to state their name, the time, and their location. Educational objective: The Glasgow Coma Scale is used to determine level of consciousness. The nurse follows a standardized assessment to determine the score of the client's eye opening response, verbal response, and ability to obey commands through a motor response.

The Nurse Assesses Several Clients Using the Glasgow Coma Scale