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Nursing QUESTION #9234
Question 1
A Head Nurse notes that an ICU patient's Glasgow Coma Scale (GCS) score is as follows: opens eyes to pain (\(E2\)), makes incomprehensible sounds (\(V2\)), flexion withdrawal to pain (\(M4\)). What is the total GCS score and what does it indicate?
  • \(\text{GCS} = 6\) — severe brain injury, immediate intubation required
  • \(\text{GCS} = 7\) — severe brain injury, intubation strongly indicated
  • \(\text{GCS} = 8\) — severe brain injury, intubation indicated (threshold \(\leq 8\))✔️
  • \(\text{GCS} = 9\) — moderate brain injury, close monitoring required
Correct Answer Explanation
Correct Answer: C — GCS = 8

GCS Calculation:
\[\text{GCS} = E + V + M = 2 + 2 + 4 = 8\]

GCS Scoring:
DomainResponseScore
Eye (E)Spontaneous4
To voice3
To pain2
None1
Verbal (V)Oriented5
Confused4
Inappropriate words3
Incomprehensible sounds2
None1
Motor (M)Obeys commands6
Localizes pain5
Withdrawal4
Flexion (Decorticate)3
Extension (Decerebrate)2
None1
GCS \(\leq 8\) = severe brain injury = airway protection threshold — intubation is indicated.