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Physiological Adaptation · Calculation · Recognize cues

A client opens the eyes only to pain, makes inappropriate words, and withdraws from a painful stimulus. What is the Glasgow Coma Scale score?

points

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Answer: 9 points

Eye opening to pain = 2; inappropriate words = 3; withdraws from pain = 4. Total = 9. A GCS of 8 or below usually indicates the need for airway protection.

Source: Teasdale & Jennett. Glasgow Coma Scale; Lewis's Med-Surg

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This question is one of 162 Physiological Adaptation items in NCLEXSim. On the NCLEX-RN, this category makes up 11–17% of the exam.

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Study tip
  • Study emergencies as a sequence: what you see, what it means, what you do first (DKA, sepsis, stroke, PE, anaphylaxis, tension pneumothorax).
  • Review fluid and electrolyte imbalances by their ECG and neuromuscular signs (peaked T waves, Chvostek and Trousseau signs).

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