Glasgow Coma Scale یا مقیاس کمای گلاسکو
در جدول زیر نمره های مقیاس کمای گلاسکو را که در آزمون NCLEX-RN مورد پرسش قرار میگیرد را مشاهده میکنید.
Glasgow Coma Scale | |
(E)ye opening | 4 – Spontaneous (open with blinking at baseline) |
3 – To speech | |
2 – To pain only | |
1 – None | |
(C – Not assessable [eg, trauma, edema]) | |
(V)erbal response | 5 – Oriented |
4 – Confused (converses but confused, disoriented) | |
3 – Inappropriate (inappropriate words) | |
2 – Incomprehensible (sounds, no words) | |
1 – None | |
(T – Not assessable [intubated]) | |
(M)otor response | 6 – Obeys commands for movement |
5 – Localizes to pain | |
4 – Withdraws from pain | |
3 – Flexion in response to pain (decorticate posturing) | |
2 – Extension in response to pain (decerebrate posturing) | |
1 – None | |
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NCLEX-RN نمونه سوال از مقیاس کمای گلاسکو در آزمون-
The nurse is triaging clients at the site of a manufacturing plant explosion. Which of the following clients should the nurse ensure is transported to the hospital first?
1. | a client who has a laceration on the left lower arm |
2. | a client who has an open fracture of the right tibia and an absent right pedal pulse |
3. | a client who has partial-thickness burns on both of the hands |
4. | a client who has a large, open head wound and a Glasgow Coma Scale score of 3 |
During a mass casualty event, the goal of the nurse is to triage rapidly and provide the greatest good for the greatest number of people. Clients are commonly triaged using a color-coded system and placed into 4 categories. When prioritizing clients for treatment, emergent needs should be managed first, followed by urgent and then nonurgent. The client with an open fracture and impaired distal perfusion (eg, absent distal pulses, capillary refill >3 sec) has an emergent need for care as limb loss may occur without rapid intervention (Option 2).
(Option 1) Depending on the size and depth of the laceration, this client would most likely be categorized as nonurgent or urgent.
(Option 3) Nonurgent treatment is appropriate for the client with partial-thickness burns to a small portion of the body (eg, hands).
(Option 4) A large, open head wound and a Glasgow Coma Scale score of 3 is indicative of severe neurological trauma. This client has a poor prognosis regardless of treatment (ie, expectant) and would be the lowest priority.
Educational objective:
During a mass casualty event, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system that establishes them with highest medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (expectant).
