Ati ew n300 med surg final proctored exam
A 52-year-old female client was admitted to the nursing unit with a severe traumatic brain injury. Upon admission she was not able to open eyes to pain, had no verbal response and she extended her left side to pain (decerebrate posturing). Using the Glasgow Coma Scale, determine her score: Eye Opening Motor Response Verbal Response Spontaneous 4 Obeys commands 6 Oriented 5 To speech 3 Localizes pain 5 Confused 4 To pain 2 Withdraw pain 4 Inappropriate 3 None 1 Abnormal flexion 3 Incomprehensible 2 Extension 2 None 1 None 1
Explanation & Rationale
A. A total score of 3 would mean no eye, motor, or verbal response. B. This would imply slightly better function than demonstrated. C. The client scores 2 for eye opening to pain, 1 for no verbal response, and 2 for extension (decerebrate) motor response, totaling a GCS of 5. D. A score of 6 would indicate better neurological function than the client demonstrates.
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