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The Nurse Assesses Several Clients Using the Glasgow Coma Scale

Question 367

Multiple Choice

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


A) The nurse applies pressure to the nail bed, and the client tries to push the nurse's hand away.  The nurse scores motor response as "localization of pain."
B) The nurse asks the client what day it is and the client says "banana."  The nurse scores verbal response as "confused."
C) The nurse speaks with client and then the client's eyes open.  The nurse scores eye opening as "spontaneous."
D) The nurse walks in the room and the client states "Hi honey.  How are you?"  The nurse scores verbal response as "oriented."

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