Question 5 : A nurse is preparing to perform a neurological assessment on a client who has a head injury. Which of the following tools should the nurse use to assess the client’s level of consciousness? A. Glasgow Coma Scale (GCS)B. Mini-Mental State Examination (MMSE)C. Confusion Assessment Method (CAM)D. Morse Fall Scale (MFS)
Explanation
The Glasgow Coma Scale (GCS) is a tool that measures the level of consciousness based on three parameters: eye opening, verbal response, and motor response. The GCS score ranges from 3 to 15, with lower scores indicating lower levels of consciousness.
Incorrect options:
B) Mini-Mental State Examination (MMSE) – This is a tool that measures cognitive function, such as orientation, memory, attention, and language. It is not used to assess level of consciousness.
C) Confusion Assessment Method (CAM) – This is a tool that screens for delirium, which is an acute and fluctuating disturbance of cognition and attention. It is not used to assess level of consciousness.
D) Morse Fall Scale (MFS) – This is a tool that assesses the risk of falling in hospitalized clients based on six factors: history of falling, secondary diagnosis, ambulatory aid, intravenous therapy, gait, and mental status. It is not used to assess level of consciousness.
